Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Niagara Rehabilitation and Nursing Center
Niagara Falls, NY · 160 certified beds · Last Life Safety survey July 15, 2024
CMS Certification Number 335742 · first certified March 1992
Ownership
Operated by THE SHERMAN FAMILY · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NY
23 citations — more than 80% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 13 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (January 2026 to August 2026). Most NY facilities have been surveyed by January 2027. This facility’s last Life Safety survey was July 2024. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 28, 2020 | 2 |
| June 16, 2022 | 8 |
| July 15, 2024 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0161 | Use approved construction type or materials. | 3 | 2024-07-15 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2024-07-15 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-07-15 |
| K-0754 | Provide properly sized and located linen or trash receptacles. | 1 | 2020-02-28 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2024-07-15 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2022-06-16 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2022-06-16 |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | 1 | 2024-07-15 |
What the citations cover
- Smoke Deficiencies 7
- Egress Deficiencies 3
- Construction Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 7
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Egress Deficiencies | 3 |
| Construction Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Electrical Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 15, 2024 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (August 28, 2024) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (August 28, 2024) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0161 | Use approved construction type or materials. | Fire Safety Evaluation Survey (August 27, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 28, 2024) |
June 16, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Fire Safety Evaluation Survey (September 23, 2022) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (July 23, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 23, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 23, 2022) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (August 1, 2022) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 23, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 26, 2022) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (July 23, 2022) |
February 28, 2020 — 2 citations
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.