Canterbury Woods

Canterbury Woods

725 Renaissance Drive

Williamsville, NY 14221

7169295800

canterburywoods.org/

Services: Baseline Services, Outpatient/Occupational Therapy, Outpatient/Physical Therapy, Outpatient/Speech Language Pathology Therapy

Beds

Behavioral Intervention:
Pediatric:
Pediatric Ventilator Dependent:
Residential Health Care:48
Transitional Care Unit:
Ventilator Dependent:
Total Number of Beds:48

Administrative

Ownership: Voluntary--Not for Profit Corporation

Operated by: Episcopal Church Home & Affiliates Life Care Community Inc
725 Renaissance Drive
Williamsville, NY 14221

Permanent Facility Identifier: 7789

Operating Certificate: 1421305N

Medicaid Certified

Medicare Certified

Medicare Number: 335816

Statistics

Employee Flu Vaccination Rate: 82%

Occupancy Rate: 100%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain20.31005/1/2019
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine82.22005/1/2019
434Percentage of short-stay residents who newly received an antipsychotic medication0.00005/1/2019
471Percentage of short-stay residents who made improvements in function57.68005/1/2019

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased8.33005/1/2019
402Percentage of long-stay residents who self-report moderate to severe pain7.57005/1/2019
404Percentage of long-stay residents who lose too much weight5.84005/1/2019
405Percentage of low risk long-stay residents who lose control of their bowels or bladder74.55005/1/2019
406Percentage of long-stay residents with a catheter inserted and left in their bladder1.25005/1/2019
407Percentage of long-stay residents with a urinary tract infection2.94005/1/2019
408Percentage of long-stay residents who have depressive symptoms0.00005/1/2019
409Percentage of long-stay residents who were physically restrained0.00005/1/2019
410Percentage of long-stay residents experiencing one or more falls with major injury4.05005/1/2019
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine96.53005/1/2019
419Percentage of long-stay residents who received an antipsychotic medication16.18005/1/2019
451Percentage of long-stay residents whose ability to move independently worsened6.77005/1/2019
452Percentage of long-stay residents who received an antianxiety or hypnotic medication14.65005/1/2019

Complaints

Number of Standard Health Deficiencies:16
Number of Live Safety Code Deficiencies:13
Number of Total Deficiencies:29
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:0
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :0
Total intakes received (last three years):37
Intakes received per 100 occupied beds (last three years):77.1
Percent of total intakes received that were facility self reported incidents (last three years):86
On-site complaint investigations (last three years):7
Complaint investigations resulting in citations (last three years):2
Complaint investigations resulting in citations per 100 occupied beds (last three years):4.2
Complaint Citations in deficiency category: Administration:0
Complaint Citations in deficiency category: Quality of Care:0
Complaint Citations in deficiency category: Resident Rights:1
Complaint Citations in deficiency category: Dietary Services:0
Complaint Citations in deficiency category: Physical Environment:0
Complaint Citations in deficiency category: Other Services:1
Complaint Citations across all deficiency categories (last three years):2

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
10/27/2017CERTIFICATION1
11/6/2018CERTIFICATION/COMPLAINT2
2/5/2018COMPLAINT2
7/9/2015CERTIFICATION2
8/8/2016CERTIFICATION2
9/8/2017CERTIFICATION/COMPLAINT2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthDEVELOP/IMPLEMENT ABUSE/NEGLECT POLICIES2111/6/20181/4/2019
HealthDRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON2211/6/20181/4/2019
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION2211/6/20181/4/2019
HealthFREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE2211/6/20181/4/2019
HealthINFECTION CONTROL2311/6/20181/4/2019
HealthINFECTION PREVENTION & CONTROL2311/6/20181/4/2019
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE2111/6/20181/4/2019
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE2111/6/20181/4/2019
LSCFUNDAMENTALS - BUILDING SYSTEM CATEGORIES2211/6/20181/4/2019
LSCSPRINKLER SYSTEM - MAINTENANCE AND TESTING2211/6/20181/4/2019
LSCSUBDIVISION OF BUILDING SPACES - SMOKE BARRIE2211/6/20181/4/2019
HealthDEPARTMENT CRIMINAL HISTORY REVIEW229/8/201710/24/2017
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY229/8/201710/24/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES229/8/201710/24/2017
HealthMAINTAINS EFFECTIVE PEST CONTROL PROGRAM219/8/201710/24/2017
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)219/8/201710/24/2017
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE229/8/201710/24/2017
LSCSPRINKLER SYSTEM - INSTALLATION229/8/201710/24/2017
HealthFREE FROM ABUSE AND NEGLECT212/5/20183/27/2018
HealthDIGNITY AND RESPECT OF INDIVIDUALITY217/9/20158/28/2015
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY227/9/20158/28/2015
LSCLIFE SAFETY CODE STANDARD227/9/20158/28/2015
LSCLIFE SAFETY CODE STANDARD227/9/20158/28/2015
LSCLIFE SAFETY CODE STANDARD227/9/20158/28/2015
LSCLIFE SAFETY CODE STANDARD227/9/20158/28/2015
LSCLIFE SAFETY CODE STANDARD227/9/20158/28/2015
LSCMISCELLANEOUS227/9/20158/28/2015
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS218/8/20169/23/2016
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES218/8/20169/23/2016