Deficiency Records for Niagara Rehabilitation and Nursing Center
Updated as of September 01, 2018
This is not the most recent data for Niagara Rehabilitation and Nursing Center. For the most recent information, click here.
A list of the most recent deficiencies for Niagara Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-16 | 2018-04-20 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Use approved construction type or materials. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2018-02-01 | 2018-03-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-02-01 | 2018-03-30 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-02-01 | 2018-03-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-02-01 | 2018-03-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-02-01 | 2018-03-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-01 | 2018-03-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-02-01 | 2018-03-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-02-01 | 2018-03-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-02-01 | 2018-03-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2018-02-01 | 2018-03-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-02-01 | 2018-03-30 | N |
| Dispose of garbage and refuse properly. | Health | 2018-02-01 | 2018-03-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-01 | 2018-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-01 | 2018-03-30 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-08-21 | 2017-09-29 | Y |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-06-28 | 2017-07-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-06-13 | 2017-07-14 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2016-12-05 | 2017-02-17 | N |
| Use approved construction type or materials. | Fire Safety | 2016-12-05 | 2017-02-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2016-12-05 | 2017-01-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2016-12-05 | 2017-01-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-12-05 | 2017-01-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2016-12-05 | 2017-01-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2016-12-05 | 2017-01-27 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2016-12-05 | 2017-01-27 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2016-12-05 | 2017-01-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2016-12-05 | 2017-01-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-12-05 | 2017-01-27 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-12-05 | 2017-01-27 | N |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2016-12-05 | 2017-01-27 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-12-05 | 2017-01-27 | N |
| Provide or obtain dental services for each resident. | Health | 2016-12-05 | 2017-01-27 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-05 | 2017-01-27 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2016-12-05 | 2017-01-27 | Y |
| Provide housekeeping and maintenance services. | Health | 2016-12-05 | 2017-01-27 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-12-05 | 2017-01-27 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-12-05 | 2017-01-27 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-12-05 | 2017-01-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-05 | 2017-01-27 | Y |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2016-12-05 | 2017-01-27 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-01-21 | 2016-04-29 | N |
| Provide housekeeping and maintenance services. | Health | 2016-01-21 | 2016-04-29 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-01-21 | 2016-04-29 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-01-21 | 2016-04-29 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-01-21 | 2016-04-29 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2016-01-21 | 2016-04-29 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-01-21 | 2016-04-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-01-21 | 2016-03-06 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-01-21 | 2016-03-06 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2016-01-21 | 2016-03-06 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2016-01-21 | 2016-03-06 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-01-21 | 2016-03-06 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-01-21 | 2016-03-06 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2016-01-21 | 2016-03-06 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-01-21 | 2016-03-06 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-01-21 | 2016-03-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2016-01-21 | 2016-03-06 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-01-21 | 2016-03-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-01-21 | 2016-03-06 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-01-21 | 2016-03-06 | Y |
| Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2016-01-21 | 2016-02-28 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-01-21 | 2016-02-28 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-01-21 | 2016-02-28 | Y |
