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621 TENTH STREET NIAGARA FALLS, NY 14302 | Voluntary non-profit - Other

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Health deficiencies are assigned during inspections that assess compliance with rules related to patient health and safety. Examples include violations of patients' rights and safety standards, as well as the administration of drugs and other treatments.

Life Safety deficiencies are assigned during inspections that assess a facility's compliance with National Fire Protection Association codes related to life safety in health care facilities. They are often conducted in tandem with health inspections. Examples include faulty or improperly maintained fire suppression and electrical systems.

Emergency Preparedness deficiencies can be cited during either a health or life safety inspection and relate to violations of CMS' Emergency Preparedness Rule. Examples include a lack of emergency plans, inadequate staff training and insufficient emergency supplies.

Complete reports and deficiency counts

Report date	Health Deficiencies	Life Safety	Emergency Preparedness	Total
Sep 9, 2025	4	0	0	4	Read full report
Deficiencies cited in this report: PATIENT RIGHTS QAPI PATIENT RIGHTS: CARE IN SAFE SETTING QUALITY IMPROVEMENT ACTIVITIES
Jun 13, 2025	1	0	0	1	Read full report
Deficiencies cited in this report: SURGICAL SERVICES
May 12, 2025	6	0	0	6	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION
Sep 25, 2023	2	0	0	2	Read full report
Deficiencies cited in this report: EMERGENCY SERVICES EMERGENCY SERVICES POLICIES
Sep 9, 2022	8	0	0	8	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION EMERGENCY SERVICES POLICIES
Apr 14, 2021	3	0	0	3	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION
Nov 3, 2020	2	0	0	2	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT SAFETY
May 10, 2019	5	0	0	5	Read full report
Deficiencies cited in this report: PHYSICAL ENVIRONMENT RN SUPERVISION OF NURSING CARE UNUSABLE DRUGS NOT USED LIFE SAFETY FROM FIRE OPERATING ROOM POLICIES
May 10, 2019	0	6	0	6	Read full report
Deficiencies cited in this report: Egress Doors Stairways and Smokeproof Enclosures Emergency Lighting Hazardous Areas - Enclosure Cooking Facilities Subdivision of Building Spaces - Smoke Barrie
Feb 11, 2019	2	0	0	2	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 MEDICAL SCREENING EXAM
Aug 7, 2018	6	0	0	6	Read full report
Deficiencies cited in this report: NURSING SERVICES PATIENT RIGHTS: PERSONAL PRIVACY RN SUPERVISION OF NURSING CARE NURSING CARE PLAN DELIVERY OF DRUGS INFECTION CONTROL PROGRAM
Nov 16, 2016	1	0	0	1	Read full report
Deficiencies cited in this report: EMERGENCY SERVICES POLICIES
May 13, 2016	1	0	0	1	Read full report
Deficiencies cited in this report: CONTENT OF RECORD: DISCHARGE SUMMARY
Mar 16, 2016	8	0	0	8	Read full report
Deficiencies cited in this report: PHYSICAL ENVIRONMENT PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CONTENT OF RECORD MAINTENANCE OF PHYSICAL PLANT DISPOSAL OF TRASH FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION CONTROL PROGRAM
Mar 16, 2016	0	2	0	2	Read full report
Deficiencies cited in this report: No Description Available No Description Available
Dec 18, 2015	4	0	0	4	Read full report
Deficiencies cited in this report: SURGICAL SERVICES PATIENT SAFETY MEDICAL RECORD SERVICES OPERATING ROOM POLICIES
Oct 8, 2015	2	0	0	2	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 MEDICAL SCREENING EXAM
Oct 7, 2015	7	0	0	7	Read full report
Deficiencies cited in this report: QUALITY IMPROVEMENT ACTIVITIES ADMINISTRATION OF DRUGS MAINTENANCE OF PHYSICAL PLANT DISPOSAL OF TRASH REGULAR FIRE AND SAFETY INSPECTIONS FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE EMERGENCY SERVICES POLICIES
Jul 14, 2014	1	0	0	1	Read full report
Deficiencies cited in this report: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
Jul 14, 2014	0	4	0	4	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available
Jun 7, 2013	1	0	0	1	Read full report
Deficiencies cited in this report: MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY
Jan 31, 2013	1	0	0	1	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE
Oct 16, 2012	2	0	0	2	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE DISCHARGE PLANNING EVALUATION
Aug 1, 2012	1	0	0	1	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE
Apr 15, 2011	1	0	0	1	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE
Oct 19, 2010	4	0	0	4	Read full report
Deficiencies cited in this report: MEDICAL STAFF - ACCOUNTABILITY PATIENT RIGHTS: CARE IN SAFE SETTING MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY RN SUPERVISION OF NURSING CARE
Aug 13, 2010	17	0	0	17	Read full report
Deficiencies cited in this report: LICENSURE OF HOSPITAL LICENSURE OF PERSONNEL MEDICAL STAFF - ACCOUNTABILITY OFF-CAMPUS EMERGENCY POLICIES AND PROCEDURES PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING ORGANIZATION OF MEDICAL STAFF CRITERIA FOR MEDICAL STAFF PRIVILEGING RN SUPERVISION OF NURSING CARE NURSING CARE PLAN CONTENT OF RECORD MEDICAL RECORD SERVICES PHARMACY ADMINISTRATION SECURE STORAGE UNUSABLE DRUGS NOT USED INFECTION CONTROL PROGRAM INTRAOPERATIVE ANESTHESIA RECORD
Aug 13, 2010	0	5	0	5	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available Multiple Occupancies - Construction Type
Aug 10, 2010	4	0	0	4	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE CONTENT OF RECORD DELIVERY OF DRUGS No Description Available
Aug 9, 2010	1	0	0	1	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE

Some state health departments and regional offices of the Centers for Medicare and Medicaid Services sometimes did not upload their inspection reports into a central computer system that could then be shared by us. In such cases, CMS identified the dates of the missing inspections and the number of deficiencies identified. You can request the actual reports from CMS or your state health department.

* Deficiencies cited in follow-up inspections are not counted toward a facility's total deficiency count.

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Complete reports and deficiency counts