Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Niagara Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control program in the main kitchen, a resident floor, and exterior dumpster areas. Surveyors repeatedly observed extensive rodent droppings on food packaging, totes, and large cans in the kitchen dry storage room, as well as in uncovered containers of salt and pepper packets during an active meal tray line. Dietary staff and leadership acknowledged ongoing rodent issues and recognized that droppings on food items were unsanitary. Multiple residents reported seeing mice in their rooms, hallways, and the main dining room, and one hallway had a visible wall hole with exposed insulation where mice had been seen. Outside, the grease dumpster and surrounding ground were coated with greasy food debris, and various discarded items were stored near the garbage dumpsters, conditions that maintenance leadership admitted could attract rodents.
A resident in an LTC facility received explicit sexual messages and a nude photo from a housekeeper, leading to a deficiency in protecting the resident from abuse. The resident, who was cognitively intact, reported the incident to an LPN, who then notified the facility's management and the police. The housekeeper was terminated, but the police did not pursue an investigation, and the facility staff believed the interaction was consensual despite its inappropriateness.
The facility failed to ensure that nurse aides employed for more than four months were certified, as two trainees worked without certification beyond the allowed timeframe. Despite completing training, they were not scheduled for testing and continued to provide care, sometimes unsupervised, due to staffing shortages. The DON and Director of Quality Assurance were unaware of the 120-day certification requirement, leading to non-compliance with state regulations.
The facility failed to maintain a clean and comfortable environment, with issues such as dirty windows, stained curtains, and disrepair in resident rooms. Staff interviews revealed a lack of awareness and responsibility for cleaning and maintenance tasks. Residents expressed dissatisfaction with the cleanliness and maintenance of their living spaces.
A resident with hypertension had duplicate medication orders for Isosorbide mononitrate and Labetalol due to transcription errors. Nursing staff signed off on both orders without notifying the medical provider for clarification. Despite awareness of the duplicate orders, no corrective actions were taken, posing a risk of double dosing.
The facility failed to adhere to food safety standards, with issues in temperature control, labeling, and dating of food items in the main kitchen and nourishment rooms. The beverage cooler in the kitchen exceeded safe temperatures, and food items were found unlabeled and undated, leading to potential hazards. Staff interviews revealed a lack of clarity and adherence to policies, contributing to the deficiencies.
The facility failed to report alleged abuse and incidents involving two residents in a timely manner. One resident with dementia was found with unexplained bruises, and another cognitively intact resident reported a physical altercation with a CNA. Both incidents were not reported to the administration immediately, violating federal regulations and facility policies.
A resident with cognitive impairment and dependency on staff for personal hygiene was not assisted with removing unwanted facial hair, despite expressing a desire to be shaved. Observations showed the resident had long facial hair, and staff interviews confirmed the expectation for shaving on shower days or as needed. The facility's inaction led to a deficiency in care.
A resident at high risk for skin breakdown due to limited mobility and incontinence was not provided with an air mattress as ordered by the physician. Despite the order, observations showed the absence of the air mattress, and nursing staff inaccurately documented its presence. The care plan and Kardex did not include the air mattress, and interviews confirmed the resident should have had one. The DON noted the order was signed off as present, highlighting a deficiency in care.
A resident with major depressive disorder was on Prozac since March 2023 without any attempted gradual dose reductions (GDR), despite no depressive symptoms. Facility policy requires GDR attempts within the first year of a new order, but staff interviews revealed a lack of awareness and action. The interdisciplinary team failed to review the resident's medication quarterly, and no psychoactive medication review notes were documented, indicating non-compliance with federal guidelines.
Failure to Maintain Effective Pest Control in Kitchen, Resident Floor, and Dumpster Areas
Penalty
Summary
The facility failed to maintain an effective pest control program in the main kitchen and on one of three resident floors, despite policies requiring the building to be kept free of insects and rodents and garbage to be removed daily. The pest control company’s service summaries from late 2025 through early 2026 documented rodent activity in the main kitchen and other facility areas on each visit. Surveyors repeatedly observed large amounts of rodent droppings in the main kitchen dry storage room on multiple days, including on top of cardboard cases of thickened dairy drinks, plastic totes of assorted dry foods, cartons of thickened drinks, and large cans of vegetables, pudding, and fruit. Staff interviews confirmed that rodents were an ongoing issue in the kitchen and that droppings were recognized as unsanitary and capable of making someone sick. On several survey dates, rodent droppings remained visible on multiple surfaces in the dry storage room, even after staff reported wiping cans and lids daily and having performed a deep cleaning of the kitchen and dry storage area in the preceding weeks. Dietary staff acknowledged seeing live mice in the dry storage room and being aware of the droppings, and one aide reported using gloves to wipe off items taken from the room. Containers of uncovered salt and pepper packets were found with rodent droppings at the bottom, and these items were still present in the dry storage area during an active breakfast tray line. Facility leadership, including the Assistant DON and Director of Quality Assurance, stated that rodent droppings on food items and in the dry storage area were an infection control problem and had the potential to make someone sick. Rodent activity was also reported and observed on the third floor resident unit. Multiple residents described seeing mice in their rooms and hallways, including mice running across hallways into rooms and mice caught on glue traps placed on the floor by maintenance. One resident reported seeing a mouse in the hallway the night before the interview, and others recalled seeing mice in the main dining room during warmer months. A resident council group expressed that they did not want rodents where they lived, describing the situation as not dignified or homelike and stating concerns about mice possibly running on them while they slept. Physical observations on the third floor included a hole in the wall behind a nightstand, with exposed insulation on the floor and a section of vinyl baseboard pulled away from the wall, in an area where staff reported prior mouse sightings. The exterior of the building was also maintained in a manner that could attract rodents. The grease dumpster had thick accumulations of greasy, food-laden debris on its lid and splattered on the ground in front and behind it, including visible food particles such as corn. Maintenance leadership acknowledged that the grease traps were emptied into the dumpster by maintenance staff and that any spilled debris should have been cleaned immediately, noting that the debris could draw rodents to the area. Additional exterior clutter, including televisions, a bed frame, a toilet, wood pallets, and empty crates, was stored near the garbage dumpsters. Facility leadership, including the Administrator and Regional Maintenance Director, were aware of rodent issues in the building and acknowledged that food debris and rodent droppings in storage and dumpster areas could attract rodents and make someone sick, while also indicating they were not fully aware of the extent of activity in the dry storage area and on the resident floor.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving a housekeeper who sent explicit sexual text messages and a nude photo to a resident. The resident, who was cognitively intact and had a history of illegal polysubstance abuse, hypertension, and a knee infection, reported feeling uncomfortable after receiving these messages. The resident had previously been advised against sharing their cell phone number with employees but did so, leading to the inappropriate communication. The incident was brought to the attention of a Licensed Practical Nurse (LPN) when the resident showed them the explicit messages and photo. The LPN reported the incident to the Supervisor and Director of Nursing, and the police were notified. The resident expressed that they were not in distress and declined counseling, although the situation was documented in their care plan as a risk for victimization. Interviews with staff and the housekeeper involved revealed that the housekeeper was terminated for their actions, although they did not recall the specific details of the messages sent. The police department did not investigate the case further, and the facility staff, including the Medical Director, believed the interaction was between consenting adults, despite acknowledging the inappropriateness of the situation.
Failure to Ensure Nurse Aide Certification Within Required Timeframe
Penalty
Summary
The facility failed to ensure that nurse aides who had been employed for more than four months were certified and competent to provide nursing and nursing-related services. Specifically, two certified nurse aide trainees had been working in the facility for over four months without completing the required nurse aide certification. The facility's policy stated that individuals could not be employed as nurse aides for more than four months without completing a state-approved training and competency evaluation program. However, there was no documented evidence of exam scheduling attempts or results for these trainees. Interviews with the nurse aide trainees revealed that they had completed their training but had not been scheduled for testing. Despite this, they were assigned duties that included providing care to residents, sometimes without supervision, due to staffing shortages. Licensed Practical Nurses and the Care Coordinator were unclear about the specific duties the trainees could perform independently and did not document supervision of the trainees' work. The Director of Nursing and the Director of Quality Assurance were unaware of the requirement for trainees to complete testing within 120 days of training. They mistakenly believed that trainees had up to 24 months to obtain certification. As a result, the trainees continued to work in the nursing department beyond the allowed timeframe without certification, contrary to the facility's policy and state regulations.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for residents across multiple floors and the main dining room. Observations revealed numerous deficiencies, including windows with dried leaves, dead insects, spider webs, and debris on both the inside and outside of windowpanes. Privacy curtains were stained, ceilings had tan stains and cracks, and water was dripping from the ceiling into a resident's room. Additionally, bathroom lights were dim and not functioning properly, and resident room walls were in disrepair with holes and exposed insulation. Interviews with staff, including housekeepers and maintenance personnel, indicated a lack of awareness and responsibility for addressing these issues. Housekeepers were unsure who was responsible for cleaning certain areas, such as window shades, and maintenance staff were not aware of some of the lighting issues. The Maintenance Director acknowledged that the facility could clean the inside of windows but required contractors for the outside due to safety concerns. However, no contractors had been hired despite previous estimates being obtained. Residents expressed dissatisfaction with the cleanliness and maintenance of their living spaces, noting that windows had been dirty for extended periods and that maintenance issues had been reported but not addressed. The facility's policies and procedures for cleaning and maintenance were not effectively implemented, leading to the observed deficiencies. The Administrator expected staff to clean resident rooms and report maintenance issues, but the lack of action and coordination between housekeeping and maintenance staff contributed to the ongoing problems.
Medication Order Transcription Error and Lack of Clarification
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for Resident #23, as outlined in the comprehensive care plan. The deficiency involved erroneous transcription of medication orders, resulting in duplicate orders for Isosorbide mononitrate and Labetalol, which were not clarified or reported to a medical provider. Nursing staff signed off on both medications as being administered on multiple occasions, despite knowing about the duplicate orders. Resident #23, who had diagnoses including end-stage renal disease, dependence on renal dialysis, and hypertension, was cognitively intact according to the Minimum Data Set. The comprehensive care plan required the administration of antihypertensive medications as ordered and obtaining blood pressure readings. However, the medication administration records showed duplicate orders for Isosorbide mononitrate and Labetalol, with nursing staff signing off on both orders without notifying the medical provider for clarification. Interviews with various Licensed Practical Nurses (LPNs) and the Director of Nursing revealed that the duplicate orders were known but not addressed. The Consultant Pharmacist had notified the Director of Nursing about the duplicate orders, but the issue remained unresolved. The Director of Nursing and the Director of Quality acknowledged the transcription errors and the potential for adverse effects due to the administration of double doses, but no corrective actions were taken at the time of the survey.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as observed during a standard survey. In the main kitchen, the beverage reach-in cooler displayed temperatures above the safe holding temperature for cold beverages, with the internal temperature reaching 48 degrees Fahrenheit and a thermometer inside showing 51 degrees Fahrenheit. This cooler contained potentially hazardous items such as milk and creamers, which were not maintained at the required temperature of 41 degrees Fahrenheit or lower. The temperature logs indicated that the cooler's temperature exceeded 40 degrees Fahrenheit on multiple occasions, and there were days with no recorded temperatures. Dietary staff were unaware of the cooler's temperature issues, and the dietary supervisor failed to notify the Dietary Director when temperatures exceeded the safe limit. In addition to temperature control issues, the facility also had problems with labeling and dating food items. In the main kitchen, an opened package of bologna and other food items were found without labels or dates. The walk-in cooler contained expired cheese and opened containers of thickened beverages without use-by dates. The nourishment rooms in Units 2 and 4 also contained unlabeled and undated food items, including resident food that was not properly identified. Staff interviews revealed a lack of clarity regarding responsibility for labeling and discarding expired food, leading to uncertainty about the ownership and age of food items in the nourishment refrigerators. The facility's policies and procedures for food storage and labeling were not consistently followed, resulting in potentially hazardous conditions. The nourishment refrigerators contained items that were not labeled with residents' names or use-by dates, and some items were past their expiration dates. Staff interviews highlighted a lack of adherence to the facility's Refrigerator Rules, which required labeling and dating of resident food and discarding items older than three days. The Dietary Director and Certified Nurse Aides acknowledged the importance of these practices but failed to ensure compliance, leading to the observed deficiencies.
Failure to Report Alleged Abuse and Incidents Timely
Penalty
Summary
The facility failed to ensure that all alleged violations, including abuse, neglect, exploitation, or mistreatment, were reported immediately, as required by federal regulations. This deficiency was identified during a standard survey, where it was found that incidents involving two residents were not reported to the facility's Administrator within the mandated timeframe. Specifically, Resident #26 was found with injuries of unknown origin, and Resident #107 was involved in a resident-to-staff altercation, neither of which were reported immediately. Resident #26, who had diagnoses including vascular dementia and rheumatoid arthritis, was found with bruises on their forehead, elbow, and hands. The incident was initially observed by a Certified Nursing Assistant and reported to a Licensed Practical Nurse, but it was not communicated to the Director of Nursing until the following day. The facility's policy requires such incidents to be reported immediately to prevent further occurrences and ensure timely investigation, which did not happen in this case. Resident #107, who was cognitively intact, reported an altercation with a Certified Nursing Assistant, where the staff member allegedly grabbed the resident's wrist during an argument. This incident was reported to a Licensed Practical Nurse, but the physical component of the altercation was not communicated to the Director of Nursing, resulting in no investigation being initiated. The facility's failure to report and investigate these incidents promptly is a violation of their policies and federal requirements.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance for personal hygiene to a resident who was unable to perform activities of daily living independently. Resident #9, who had diagnoses including metabolic encephalopathy, diabetes, and schizoaffective disorder, required assistance for personal hygiene as documented in their care plan. Despite being cognitively impaired, Resident #9 was able to communicate their dislike for facial hair and had requested razors from staff. Observations from 7/9/24 to 7/15/24 revealed that Resident #9 had long facial hair on their upper lip, chin, and neck, and was not assisted in removing it, despite expressing a desire to be shaved. Interviews with staff, including Certified Nurse Aide #7, LPN #4, and the Director of Nursing, confirmed that the expectation was for residents to be shaved on shower days or when needed. However, Resident #9 was not provided with this care, as evidenced by multiple observations where staff did not assist with shaving despite the resident's requests. The Director of Nursing acknowledged that not shaving a resident who preferred to be clean-shaven was a dignity issue. The facility's failure to assist Resident #9 with personal hygiene needs, specifically the removal of unwanted facial hair, constituted a deficiency in care.
Failure to Provide Ordered Air Mattress for High-Risk Resident
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with pressure ulcers, as per professional standards of practice. Specifically, the resident, who was at high risk for skin breakdown due to limited mobility and incontinence, was not provided with an air mattress as ordered by the physician. Despite the physician's order for an air mattress to be in place at all times to promote skin integrity, observations revealed that the resident did not have an air mattress in place during multiple checks. The resident had a history of pressure ulcers, including a Stage 2 and a Stage 4 ulcer, and was documented as being at risk for developing new ulcers. The care plan and Kardex did not include the use of an air mattress, and nursing staff inaccurately documented that the air mattress was in place every shift. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the resident should have had an air mattress due to their high risk for skin breakdown, but it was not provided. The Director of Nursing acknowledged that the air mattress order was being signed off as present every shift, despite it not being in place. The expectation was that the nursing staff would notify their superiors or maintenance if the air mattress was not in place as per the physician's order. This oversight in providing the ordered air mattress and the inaccurate documentation contributed to the deficiency in care for the resident.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication underwent gradual dose reductions (GDR) as required by federal regulations. Specifically, a resident with a diagnosis of major depressive disorder had been on Prozac since March 2023 without any attempted GDR, despite the absence of depressive symptoms or behaviors. The facility's policy mandates GDR attempts in two separate quarters within the first year of a new order, unless clinically contraindicated, but no such attempts were documented for this resident. Interviews with various staff members, including a medical provider, LPNs, and the Director of Nursing, revealed a lack of awareness and action regarding the need for GDR for the resident's Prozac. The medical provider admitted to not recalling any recent GDR attempts, and the consultant pharmacist did not request a GDR due to the resident's diagnosis. The interdisciplinary team, which should have reviewed the resident's medication quarterly, had not done so since the Director of Nursing's tenure began in December 2023. The Director of Quality confirmed that the facility should have been conducting monthly GDR meetings and that the resident's Prozac dosage should have been reviewed for possible reduction. The absence of documented psychoactive medication review notes in the resident's electronic medical record further highlighted the facility's failure to comply with federal guidelines, which require GDR attempts twice within the first year of a new order and annually thereafter unless contraindicated.
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What surveyors actually found near you
We read the 151 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Niagara Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Schoellkopf Health Center | 0.3 mi | ★★★★★ | 13 | 0 |
| Our Lady Of Peace Nursing Care Residence | 4.1 mi | ★★★★★ | 0 | 0 |
| Elderwood At Grand Island | 5.4 mi | ★★★★★ | 1 | 0 |
| Elderwood At Wheatfield | 7.4 mi | ★★★★★ | 0 | 0 |
| North Gate Health Care Facility | 9.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.