Inspection Reports for
Lockport Rehab & Health Care Center
909 Lincoln Ave, Lockport, NY, 14094
Back to Facility Profile4 Reports
Inspection Report — Mar 11, 2026
State
Date: Mar 11, 2026
Visit Reason
State-compiled facility profile showing 7 inspections from June 2022 to May 2026 with citation and complaint history.
Complaint Details
The facility received 48 complaints with 12 on-site inspections conducted. One citation resulted from those complaints.
Findings
Across 7 inspections, 4 had no citations while 3 inspections resulted in 32 citations, including 13 standard health and 19 Life Safety Code violations. The facility received 48 complaints with 12 on-site inspections and no formal enforcement actions recorded.
Citations (32)
Standard Health Citation — quality of care: Bedrails issue noted.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and sanitary issues.
Standard Health Citation — quality of care: Grievances not properly handled.
Standard Health Citation — quality of care: Infection control deficiencies.
Standard Health Citation — quality of care: Posted nurse staffing information inaccurate or incomplete.
Standard Health Citation — quality of care: Resident bed issues.
Life Safety Code Citation — NFPA requirements: Cooking facilities deficiencies.
Life Safety Code Citation — NFPA requirements: Development of emergency policies and procedures inadequate.
Life Safety Code Citation — NFPA requirements: Electrical equipment testing and maintenance issues.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance deficiencies.
Life Safety Code Citation — NFPA requirements: Hazardous areas enclosure problems.
Life Safety Code Citation — NFPA requirements: Names and contact information not properly maintained.
Life Safety Code Citation — NFPA requirements: Plan based on all hazards risk assessment inadequate.
Life Safety Code Citation — NFPA requirements: Subdivision of building spaces - smoke barriers deficient.
Standard Health Citation — quality of care: ADL care provided for dependent residents deficient.
Standard Health Citation — quality of care: Self-determination issues.
Standard Health Citation — quality of care: Tube feeding management and restoration of eating skills deficient.
Life Safety Code Citation — NFPA requirements: Electrical equipment power cords and extensions issues.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system deficiencies.
Life Safety Code Citation — NFPA requirements: Exit signage problems.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance deficiencies.
Life Safety Code Citation — NFPA requirements: Smoke detection issues.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing deficient.
Life Safety Code Citation — NFPA requirements: Subdivision of building spaces - smoke barriers deficient.
Standard Health Citation — quality of care: Bowel/bladder incontinence, catheter, UTI issues.
Standard Health Citation — quality of care: Free from abuse and neglect violations.
Standard Health Citation — quality of care: Notify of changes (injury/decline/room, etc.) deficient.
Standard Health Citation — quality of care: Reporting of alleged violations deficient.
Life Safety Code Citation — NFPA requirements: Cooking facilities deficiencies.
Life Safety Code Citation — NFPA requirements: Corridors construction of walls deficient.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance deficiencies.
Life Safety Code Citation — NFPA requirements: Hazardous areas enclosure problems.
Report Facts
Inspections on page: 7
Total violations/deficiencies cited: 32
Inspections with violations: 3
Inspections without violations: 4
Total complaints: 48
On-site complaint inspections: 12
Citations from complaints: 1
Total enforcement actions: 0
Inspection Report — Jun 4, 2024
Complaint Investigation CMS
Date: Jun 4, 2024
Visit Reason
The visit was conducted as a complaint investigation regarding concerns about resident care, including resident rights to self-determination, personal hygiene, and feeding tube management.
Complaint Details
Complaint investigation (Complaint #NY00323467) focused on feeding tube care for Resident #127 and other resident care issues. The complaint was substantiated with findings of inadequate feeding tube management and other care deficiencies.
Findings
The facility failed to ensure that Resident #9 received showers according to their care plan and preferences, resulting in a violation of resident rights. Resident #29 did not receive adequate nail care, with long, jagged nails observed despite care plans. Resident #127 did not receive prescribed enteral feeding formula as per hospital discharge orders, risking inadequate nutrition and hydration.
Citations (3)
F 0561: The facility did not ensure Resident #9 received showers twice a week during the day as care planned and preferred, instead providing one shower weekly in the evening.
F 0677: The facility did not ensure Resident #29 received necessary nail care; nails were long, jagged, and dirty despite care plans and staff awareness.
F 0693: The facility failed to provide Resident #127 with the prescribed enteral feeding formula per hospital discharge summary, resulting in missed nutrition and hydration for over 15 hours.
Report Facts
Deficiencies cited: 3
Feeding rate: 70
Water flush volume: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Supervisor #1 | Licensed Practical Nurse Supervisor | Named in feeding tube formula omission and communication failure. |
| Certified Nursing Aide #1 | Certified Nursing Aide | Interviewed regarding shower scheduling and care for Resident #9. |
| Certified Nursing Aide #2 | Certified Nursing Aide | Interviewed regarding shower scheduling and nail care. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding nail care responsibilities for Resident #29. |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding nail care for Resident #29. |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Interviewed regarding shower scheduling and care plan updates for Resident #9. |
| Director of Nursing | Director of Nursing | Interviewed regarding shower scheduling, nail care expectations, and feeding tube formula issues. |
| Administrator | Administrator | Interviewed regarding expectations for honoring Resident #9's preferences. |
| Nurse Practitioner #1 | Nurse Practitioner | Interviewed regarding feeding tube orders and expectations for nursing staff. |
| Registered Dietitian | Registered Dietitian | Interviewed regarding feeding tube formula supply and recommendations. |
Inspection Report — Jun 28, 2022
Routine CMS
Date: Jun 28, 2022
Visit Reason
The inspection was a standard survey conducted to assess compliance with regulatory requirements related to resident care, abuse prevention, and catheter care at Lockport Rehab & Health Care Center.
Findings
The facility failed to notify a resident's responsible party prior to initiating psychotropic medication, did not prevent resident-to-resident abuse resulting in a skin tear, failed to timely report the abuse incident to the state, and did not ensure proper anchoring of an indwelling urinary catheter for one resident.
Citations (4)
F 0580: The facility did not inform Resident #55's responsible party prior to starting antipsychotic medication (Zyprexa) for dementia-related aggression.
F 0600: Resident #55 was bitten by Resident #75, causing a skin tear, and the facility failed to ensure resident rights to be free from abuse and to prevent further incidents.
F 0609: The facility did not report the resident-to-resident abuse incident involving Residents #55 and #75 to the New York State Department of Health within the required 2-hour timeframe.
F 0690: Resident #44's indwelling urinary catheter was not anchored to prevent tension, and the facility policy did not address catheter anchoring.
Report Facts
Skin tear size: 3
Medication dosage: 2.5
Antibiotic dosage: 500
Incident notification time: 2
Catheter flush volume: 50
Catheter size: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Unit Manager | Did not notify family when Resident #55 was started on Zyprexa. |
| RN #1 | Unit Manager | Completed incident report and investigation of resident-to-resident abuse involving Residents #55 and #75. |
| Director of Nursing | Director of Nursing | Stated expectation to notify family of medication changes and reported on abuse incident handling and reporting. |
| LPN #2 | Licensed Practical Nurse | Observed Resident #44's catheter was not anchored and acknowledged responsibility for catheter care. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Witnessed resident-to-resident biting incident. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Provided catheter care to Resident #44 and noted catheter was not anchored. |
Inspection Report — Aug 30, 2019
Routine CMS
Date: Aug 30, 2019
Visit Reason
The facility underwent a standard routine survey inspection to assess compliance with regulatory requirements including employee screening, resident assessments, medication management, and food service quality.
Findings
The inspection identified deficiencies in employee pre-hire screening procedures, inaccurate resident assessments related to psychotropic medication dose reductions, failure to implement gradual dose reductions (GDR) for antipsychotic medications, and issues with food service including improper food temperatures and poor food quality.
Citations (5)
F 0607: The facility failed to implement written policies and procedures for screening employees to prevent abuse, neglect, and exploitation, with four of fifteen employee files lacking timely Nurse Aide Registry verification prior to employment.
F 0641: The facility did not ensure accurate resident assessments reflecting recent gradual dose reductions (GDR) of psychotropic medications for two residents, resulting in inaccurate Minimum Data Set (MDS) entries.
F 0756: The pharmacist failed to report irregularities in medication regimens for two residents, specifically not identifying or reporting antipsychotic medications prescribed without attempts at gradual dose reduction (GDR).
F 0758: The facility did not ensure residents using antipsychotic drugs received gradual dose reductions or behavioral interventions unless contraindicated, with two residents maintained on antipsychotics without documented GDR or behavioral justification.
F 0804: The facility failed to provide food and drink that was palatable, attractive, and served at safe and appetizing temperatures, with observations of lukewarm or cold food and resident complaints about food quality.
Report Facts
Employee files lacking timely Nurse Aide Registry verification: 4
Resident count reviewed for MDS accuracy: 23
Residents reviewed for Drug Regimen Reviews: 5
Residents reviewed for antipsychotic medication use: 2
Medication refusal instances: 49
Food temperature measurements: 118
Food temperature measurements: 104
Food temperature measurements: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources and Payroll Coordinator | Interviewed regarding employee screening and Nurse Aide Registry verification errors. | |
| Director of Nursing | Interviewed about resident assessments and medication management. | |
| Pharmacist Consultant #1 | Pharmacist Consultant | Interviewed regarding medication regimen reviews and GDR implementation. |
| Licensed Practical Nurse Unit Manager #1 | LPN Unit Manager | Interviewed about MDS completion and resident behaviors. |
| Medical Director | Medical Director | Interviewed about pharmacy reviews and medication management. |
| Food Service Director | Food Service Director | Interviewed about food service quality and temperature monitoring. |
Viewing
Loading inspection reports...
