Comprehensive Rehabilitation and Nursing Center at Williamsville

Comprehensive Rehabilitation and Nursing Center at Williamsville

147 Reist Street

Williamsville, NY 14221

7166335400

www.chsbuffalo.org/Facilities/NursingHomes/StFrancis

Services: Baseline Services

Beds

Behavioral Intervention:
Pediatric:
Pediatric Ventilator Dependent:
Residential Health Care:142
Transitional Care Unit:
Ventilator Dependent:
Total Number of Beds:142

Administrative

Ownership: Proprietary--LLC

Operated by: Comprehensive at Williamsville LLC
147 and 149 Reist Street
Williamsville, NY 14221

Permanent Facility Identifier: 274

Operating Certificate: 1421308N

Medicaid Certified

Medicare Certified

Medicare Number: 335172

Statistics

Employee Flu Vaccination Rate: 40%

Occupancy Rate: 88%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain25.3910/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened0.846000000000000110/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine65.97610/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine76.80310/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication6.20310/1/2017
471Percentage of short-stay residents who made improvements in function77.54510/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased25.0602000010/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain6.4155000010/1/2017
403Percentage of high risk long-stay residents with pressure ulcers7.0028000010/1/2017
404Percentage of long-stay residents who lose too much weight7.4074000010/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder72.9412000010/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder3.0716000010/1/2017
407Percentage of long-stay residents with a urinary tract infection0.2315000010/1/2017
408Percentage of long-stay residents who have depressive symptoms7.7859000010/1/2017
409Percentage of long-stay residents who were physically restrained0.0000000010/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury3.4483000010/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine85.7143000010/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine90.3448000010/1/2017
419Percentage of long-stay residents who received an antipsychotic medication12.8641000010/1/2017
451Percentage of long-stay residents whose ability to move independently worsened30.1321000010/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication13.3803000010/1/2017

Complaints

Number of Standard Health Deficiencies:111
Number of Live Safety Code Deficiencies:56
Number of Total Deficiencies:167
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:3
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :2
Total intakes received (last three years):114
Intakes received per 100 occupied beds (last three years):87.4
Percent of total intakes received that were facility self reported incidents (last three years):32
On-site complaint investigations (last three years):41
Complaint investigations resulting in citations (last three years):41
Complaint investigations resulting in citations per 100 occupied beds (last three years):31.4
Complaint Citations in deficiency category: Administration:2
Complaint Citations in deficiency category: Quality of Care:21
Complaint Citations in deficiency category: Resident Rights:13
Complaint Citations in deficiency category: Dietary Services:3
Complaint Citations in deficiency category: Physical Environment:2
Complaint Citations in deficiency category: Other Services:0
Complaint Citations across all deficiency categories (last three years):41

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed
1/24/2011 0:00Quality of Care1/10/20122000
10/28/2010 0:00Quality of Care1/18/201210000
2/29/2016 0:00Quality of Care6/28/201620000
3/23/2007 0:00Quality of Care2/26/20081000
6/8/2016 0:00Multiple Deficiencies12/6/201621000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
12/10/2013Certification2
12/18/2014Certification2
2/14/2017Complaint2
2/29/2016Complaint2
6/11/2015Complaint2
6/8/2016Certification4
6/8/2017Certification3
7/14/2016Complaint2
8/20/2015Certification3

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate citation corrected
LSCHazardous Areas - Enclosure22
LSCSubdivision of Building Spaces - Smoke Barrie22
LSCElectrical Equipment - Power Cords and Extens22
LSCElectrical Equipment - Testing and Maintenanc22
LSCGas Equipment - Cylinder and Container Storag22
LSCLIFE SAFETY CODE STANDARD221/21/2014
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)211/31/2014
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP211/31/2014
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING211/31/2014
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES211/31/2014
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER211/31/2014
LSCLIFE SAFETY CODE STANDARD221/31/2014
LSCLIFE SAFETY CODE STANDARD221/31/2014
LSCLIFE SAFETY CODE STANDARD221/31/2014
LSCLIFE SAFETY CODE STANDARD221/31/2014
HealthRequirements Before Submitting a Request for2210/20/2015
HealthCriminal History Record Check Process2210/20/2015
HealthCriminal History Record Check Process2210/20/2015
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)2110/20/2015
HealthPERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS2110/20/2015
HealthRIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES2210/20/2015
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES2210/20/2015
HealthRIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE2110/20/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2110/20/2015
HealthINCREASE/PREVENT DECREASE IN RANGE OF MOTION2110/20/2015
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS2210/20/2015
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS2210/20/2015
HealthSUFFICIENT DIETARY SUPPORT PERSONNEL2210/20/2015
HealthFOOD IN FORM TO MEET INDIVIDUAL NEEDS2110/20/2015
HealthPHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH2110/20/2015
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS2110/20/2015
HealthLAB SVCS ONLY WHEN ORDERED BY PHYSICIAN2110/20/2015
LSCLIFE SAFETY CODE STANDARD2110/20/2015
LSCLIFE SAFETY CODE STANDARD2210/20/2015
LSCLIFE SAFETY CODE STANDARD2210/20/2015
LSCLIFE SAFETY CODE STANDARD2310/20/2015
LSCLIFE SAFETY CODE STANDARD2210/20/2015
LSCLIFE SAFETY CODE STANDARD2210/20/2015
LSCLIFE SAFETY CODE STANDARD2310/20/2015
LSCLIFE SAFETY CODE STANDARD2110/20/2015
LSCLIFE SAFETY CODE STANDARD2210/20/2015
LSCLIFE SAFETY CODE STANDARD2210/20/2015
HealthPhysical Environment2210/20/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING2110/26/2016
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS2110/26/2016
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS2111/20/2015
HealthRIGHT TO SURVEY RESULTS - READILY ACCESSIBLE1211/30/2015
HealthDEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES2211/30/2015
HealthCOMPREHENSIVE ASSESSMENTS2111/30/2015
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP2211/30/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING2211/30/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES2211/30/2015
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES2211/30/2015
HealthMAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE2211/30/2015
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY2211/30/2015
HealthDRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON2211/30/2015
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION2111/30/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE2211/30/2015
HealthQAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS2211/30/2015
LSCLIFE SAFETY CODE STANDARD2211/30/2015
LSCLIFE SAFETY CODE STANDARD2211/30/2015
HealthHOUSEKEEPING & MAINTENANCE SERVICES2212/13/2015
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS212/13/2015
HealthCOMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE212/13/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS212/13/2015
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP212/13/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING212/13/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS212/13/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES212/13/2015
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES212/13/2015
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS222/13/2015
HealthNUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP212/13/2015
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY212/13/2015
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS212/13/2015
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS212/13/2015
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION222/13/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE212/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
LSCLIFE SAFETY CODE STANDARD222/13/2015
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)213/1/2017
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS213/1/2017
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES314/28/2016
HealthDIGNITY AND RESPECT OF INDIVIDUALITY224/28/2016
HealthHOUSEKEEPING & MAINTENANCE SERVICES224/28/2016
HealthADMISSION PHYSICIAN ORDERS FOR IMMEDIATE CARE214/28/2016
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING314/28/2016
HealthMENUS MEET RES NEEDS/PREP IN ADVANCE/FOLLOWED224/28/2016
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY224/28/2016
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION224/28/2016
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE214/28/2016
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION226/29/2015
HealthCriminal History Record Check Process237/14/2016
HealthCriminal History Record Check Process237/14/2016
HealthDepartment Criminal History Review217/14/2016
HealthResponsibilities of Providers; Required Notif227/14/2016
HealthFACILITY MANAGEMENT OF PERSONAL FUNDS217/14/2016
HealthSURETY BOND - SECURITY OF PERSONAL FUNDS217/14/2016
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS237/14/2016
HealthDEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES237/14/2016
HealthREASONABLE ACCOMMODATION OF NEEDS/PREFERENCES217/14/2016
HealthRIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE217/14/2016
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT217/14/2016
HealthCOMPREHENSIVE ASSESSMENT 14 DAYS AFTER ADMIT227/14/2016
HealthCOMPREHENSIVE ASSESS AT LEAST EVERY 12 MONTHS217/14/2016
HealthQUARTERLY ASSESSMENT AT LEAST EVERY 3 MONTHS227/14/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS217/14/2016
HealthTREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS217/14/2016
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER217/14/2016
HealthINCREASE/PREVENT DECREASE IN RANGE OF MOTION227/14/2016
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES227/14/2016
HealthMAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE217/14/2016
HealthSUFFICIENT FLUID TO MAINTAIN HYDRATION217/14/2016
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS217/14/2016
HealthINFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS217/14/2016
HealthSUFFICIENT 24-HR NURSING STAFF PER CARE PLANS227/14/2016
HealthFREQUENCY & TIMELINESS OF PHYSICIAN VISIT217/14/2016
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS227/14/2016
HealthRESIDENT CALL SYSTEM - ROOMS/TOILET/BATH217/14/2016
HealthEFFECTIVE ADMINISTRATION/RESIDENT WELL-BEING237/14/2016
HealthNURSE AIDE PERFORM REVIEW-12 HR/YR INSERVICE237/14/2016
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE217/14/2016
HealthQAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS237/14/2016
LSCLIFE SAFETY CODE STANDARD217/14/2016
LSCLIFE SAFETY CODE STANDARD227/14/2016
LSCLIFE SAFETY CODE STANDARD217/14/2016
LSCLIFE SAFETY CODE STANDARD227/14/2016
LSCLIFE SAFETY CODE STANDARD227/14/2016
LSCLIFE SAFETY CODE STANDARD227/14/2016
LSCLIFE SAFETY CODE STANDARD227/14/2016
HealthOrganization and Administration227/14/2016
LSCMeans of Egress - General227/14/2017
LSCExit Signage227/14/2017
LSCSoiled Linen and Trash Containers227/14/2017
LSCElectrical Systems - Other227/14/2017
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)217/21/2017
LSCStairways and Smokeproof Enclosures227/21/2017
LSCDischarge from Exits227/21/2017
LSCVertical Openings - Enclosure227/21/2017
LSCFire Alarm System - Installation227/21/2017
LSCFire Alarm System - Testing and Maintenance227/21/2017
LSCSprinkler System - Maintenance and Testing227/21/2017
LSCCorridor - Doors227/21/2017
HealthCLEAN BED/BATH LINENS IN GOOD CONDITION127/28/2017
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES217/28/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES227/28/2017
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS217/28/2017
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION227/28/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES217/29/2016
LSCLIFE SAFETY CODE STANDARD228/3/2016
HealthRequirements Before Submitting a Request for129/7/2016
HealthRIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES219/7/2016
HealthDIGNITY AND RESPECT OF INDIVIDUALITY229/7/2016
HealthSERVICES BY QUALIFIED PERSONS/PER CARE PLAN219/7/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES319/7/2016
LSCLIFE SAFETY CODE STANDARD229/7/2016
LSCLIFE SAFETY CODE STANDARD229/7/2016