Cycle 1
Health 2024-07-15 · Fire 2024-07-15
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Niagara Falls, NY
Niagara Rehabilitation And Nursing Center
1-star overall rating with 2-star inspections with 7 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
822 Cedar Avenue, Niagara Falls, NY
(716) 282-1207
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
149
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Sherman Family
Operator or chain grouping
Approved since
1992-03-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.59
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.66
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.08
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.24
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
2.78
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,369
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.83
Performance 20.12% · Measure score 2.83 · Achievement 2.83 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.45
Performance 6.21% · Measure score 5.45 · Achievement 5.45 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.69
Baseline 65.35% · Performance 48.60% · Measure score 3.69 · Achievement 3.69 · Improvement 3.64
Adjusted total nurse staffing
0
Baseline 3.04 hours · Performance 2.93 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 13.33% · Lower 95% interval 7.91% |
| Discharge to community | 41.56% |
50.57%
9 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 30.77% · Lower 95% interval 28.37% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.91% |
95.27%
1.6 pts better
|
Numerator 94 · Denominator 97 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 97 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 30 · Denominator 70 |
| Discharge mobility score | 38.57% |
50.94%
12.4 pts worse
|
Numerator 27 · Denominator 70 |
| Pressure ulcers or injuries, new or worsened | 5.15% |
2.29%
2.9 pts worse
|
Numerator 5 · Denominator 97 · Adjusted rate 5.54% |
| Healthcare-associated infections requiring hospitalization | 6.2% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 2.5% · Lower 95% interval 3.46% |
| Staff COVID-19 vaccination coverage | 15.23% |
8.2%
7 pts better
|
Numerator 30 · Denominator 197 |
| Staff flu vaccination coverage | 50.61% |
42%
8.6 pts better
|
Numerator 83 · Denominator 164 |
| Discharge function score | 45.71% |
56.45%
10.7 pts worse
|
Numerator 32 · Denominator 70 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 75.86% |
96.28%
20.4 pts worse
|
Numerator 22 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 21.43% |
25.2%
3.8 pts worse
|
Numerator 9 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
91.2%
1.4 pts better
|
93.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.8% · Q2 93.8% · Q3 91.3% · Q4 92.4% · 4Q avg 92.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.3% |
95.3%
13 pts worse
|
95.5%
13.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.0%
1.8 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 0.8% · Q4 0.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.7% |
18.5%
0.8 pts better
|
11.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 17.9% · Q3 20.2% · Q4 14.2% · 4Q avg 17.7% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
6.1%
3.1 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 3.1% · Q3 4.8% · Q4 3.1% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
13.5%
0.2 pts worse
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 14.0% · Q3 12.8% · Q4 13.6% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.4% |
14.8%
0.6 pts worse
|
16.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 19.7% · Q3 11.4% · Q4 16.9% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.2% |
0.2%
About the same
|
0.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.8% |
15.1%
2.7 pts worse
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 18.5% · Q3 19.7% · Q4 13.9% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
15.5%
0.8 pts better
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 21.3% · Q3 12.4% · Q4 9.4% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.6%
1.4 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 3.4% · Q3 2.3% · Q4 1.2% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
20.8%
1.3 pts better
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 25.1% · Q3 20.8% · Q4 16.3% · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.9%
2.3 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 7.0% · Q3 2.6% · Q4 4.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.1% |
76.7%
19.6 pts worse
|
81.7%
24.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.7% · Q2 50.0% · Q3 77.0% · Q4 58.3% · 4Q avg 57.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.8% |
9.7%
6.1 pts worse
|
12.0%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 18.8% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.2%
2 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.0% · Q3 4.2% · Q4 2.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.2% |
78.8%
20.6 pts worse
|
79.7%
21.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
20.6%
1.4 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 21.9% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-16 · Fire 2022-06-16
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2020-02-28 · Fire 2020-02-28
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-15
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-07-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-15
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-15
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-15
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-08-28
C · Minimal harm
2024-07-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-08-28
C · Minimal harm
2024-07-15
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-28
C · Minimal harm
2024-07-15
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-08-28
E · Potential for more than minimal harm
2022-06-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-06-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-06-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-06-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-06-16
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-08-01
E · Potential for more than minimal harm
2022-06-16
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-06-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-26
E · Potential for more than minimal harm
2022-06-16
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-07-23
E · Potential for more than minimal harm
2020-02-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Not marked corrected
E · Potential for more than minimal harm
2020-02-28
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2020-04-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-30
E · Potential for more than minimal harm
2024-11-20
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-07-15
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-15
F758 · Pharmacy Service Deficiencies
Health
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 necessary and PRN use is limited.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-02-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-05
D · Potential for more than minimal harm
2023-12-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-01
E · Potential for more than minimal harm
2022-06-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-06-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-06-16
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-07-23
E · Potential for more than minimal harm
2020-02-28
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2020-04-20
D · Potential for more than minimal harm
2020-02-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-04-20
D · Potential for more than minimal harm
2020-02-28
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2020-04-20
D · Potential for more than minimal harm
2020-02-28
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2020-04-20
D · Potential for more than minimal harm
2020-02-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-04-20
Penalties and ownership
What sits behind the stars
Ownership
Niagara Investors, LLC
5% Or Greater Direct Ownership Interest · Organization
Goldstein, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Sherman, Samuel
5% Or Greater Direct Ownership Interest · Individual
Sherman, Israel
5% Or Greater Direct Ownership Interest · Individual
Fadeley, Peter
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Schoellkopf Health Center
Niagara Falls, NY
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Our Lady Of Peace Nursing Care Residence
Lewiston, NY
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#3
Elderwood At Grand Island
Grand Island, NY
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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