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 pain25.389812/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened0.845612/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine65.976312/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine76.803412/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication6.203512/1/2017
471Percentage of short-stay residents who made improvements in function77.545012/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased25.060212/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain6.415512/1/2017
403Percentage of high risk long-stay residents with pressure ulcers7.002812/1/2017
404Percentage of long-stay residents who lose too much weight7.407412/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder72.941212/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder3.071612/1/2017
407Percentage of long-stay residents with a urinary tract infection0.231512/1/2017
408Percentage of long-stay residents who have depressive symptoms7.785912/1/2017
409Percentage of long-stay residents who were physically restrained0.000012/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury3.448312/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine85.714312/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine90.344812/1/2017
419Percentage of long-stay residents who received an antipsychotic medication12.864112/1/2017
451Percentage of long-stay residents whose ability to move independently worsened30.132112/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication13.380312/1/2017

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
6/8/2017Certification5
7/14/2016Complaint2
8/20/2015Certification3

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
LSCLIFE SAFETY CODE STANDARD2212/10/20131/21/2014
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)2112/10/20131/31/2014
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP2112/10/20131/31/2014
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING2112/10/20131/31/2014
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES2112/10/20131/31/2014
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER2112/10/20131/31/2014
LSCLIFE SAFETY CODE STANDARD2212/10/20131/31/2014
LSCLIFE SAFETY CODE STANDARD2212/10/20131/31/2014
LSCLIFE SAFETY CODE STANDARD2212/10/20131/31/2014
LSCLIFE SAFETY CODE STANDARD2212/10/20131/31/2014
HealthRequirements Before Submitting a Request for228/20/201510/20/2015
HealthCriminal History Record Check Process228/20/201510/20/2015
HealthCriminal History Record Check Process228/20/201510/20/2015
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)218/20/201510/20/2015
HealthPERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS218/20/201510/20/2015
HealthRIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES228/20/201510/20/2015
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES228/20/201510/20/2015
HealthRIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE218/20/201510/20/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS218/20/201510/20/2015
HealthINCREASE/PREVENT DECREASE IN RANGE OF MOTION218/20/201510/20/2015
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS228/20/201510/20/2015
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS228/20/201510/20/2015
HealthSUFFICIENT DIETARY SUPPORT PERSONNEL228/20/201510/20/2015
HealthFOOD IN FORM TO MEET INDIVIDUAL NEEDS218/20/201510/20/2015
HealthPHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH218/20/201510/20/2015
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS218/20/201510/20/2015
HealthLAB SVCS ONLY WHEN ORDERED BY PHYSICIAN218/20/201510/20/2015
LSCLIFE SAFETY CODE STANDARD218/20/201510/20/2015
LSCLIFE SAFETY CODE STANDARD228/20/201510/20/2015
LSCLIFE SAFETY CODE STANDARD228/20/201510/20/2015
LSCLIFE SAFETY CODE STANDARD238/20/201510/20/2015
LSCLIFE SAFETY CODE STANDARD228/20/201510/20/2015
LSCLIFE SAFETY CODE STANDARD228/20/201510/20/2015
LSCLIFE SAFETY CODE STANDARD238/20/201510/20/2015
LSCLIFE SAFETY CODE STANDARD218/20/201510/20/2015
LSCLIFE SAFETY CODE STANDARD228/20/201510/20/2015
LSCLIFE SAFETY CODE STANDARD228/20/201510/20/2015
HealthPhysical Environment228/20/201510/20/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING216/8/201610/26/2016
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS216/8/201610/26/2016
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS218/20/201511/20/2015
HealthRIGHT TO SURVEY RESULTS - READILY ACCESSIBLE128/20/201511/30/2015
HealthDEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES228/20/201511/30/2015
HealthCOMPREHENSIVE ASSESSMENTS218/20/201511/30/2015
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP228/20/201511/30/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING228/20/201511/30/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES228/20/201511/30/2015
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES228/20/201511/30/2015
HealthMAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE228/20/201511/30/2015
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY228/20/201511/30/2015
HealthDRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON228/20/201511/30/2015
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION218/20/201511/30/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE228/20/201511/30/2015
HealthQAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS228/20/201511/30/2015
LSCLIFE SAFETY CODE STANDARD228/20/201511/30/2015
LSCLIFE SAFETY CODE STANDARD228/20/201511/30/2015
HealthHOUSEKEEPING & MAINTENANCE SERVICES228/20/201512/13/2015
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS2112/18/20142/13/2015
HealthCOMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE2112/18/20142/13/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS2112/18/20142/13/2015
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP2112/18/20142/13/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING2112/18/20142/13/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2112/18/20142/13/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES2112/18/20142/13/2015
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES2112/18/20142/13/2015
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS2212/18/20142/13/2015
HealthNUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP2112/18/20142/13/2015
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY2112/18/20142/13/2015
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS2112/18/20142/13/2015
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS2112/18/20142/13/2015
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION2212/18/20142/13/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE2112/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
LSCLIFE SAFETY CODE STANDARD2212/18/20142/13/2015
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)212/14/20173/1/2017
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS212/14/20173/1/2017
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES312/29/20164/28/2016
HealthDIGNITY AND RESPECT OF INDIVIDUALITY222/29/20164/28/2016
HealthHOUSEKEEPING & MAINTENANCE SERVICES222/29/20164/28/2016
HealthADMISSION PHYSICIAN ORDERS FOR IMMEDIATE CARE212/29/20164/28/2016
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING312/29/20164/28/2016
HealthMENUS MEET RES NEEDS/PREP IN ADVANCE/FOLLOWED222/29/20164/28/2016
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY222/29/20164/28/2016
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION222/29/20164/28/2016
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE212/29/20164/28/2016
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION226/11/20156/29/2015
HealthCriminal History Record Check Process236/8/20167/14/2016
HealthCriminal History Record Check Process236/8/20167/14/2016
HealthDepartment Criminal History Review216/8/20167/14/2016
HealthResponsibilities of Providers; Required Notif226/8/20167/14/2016
HealthFACILITY MANAGEMENT OF PERSONAL FUNDS216/8/20167/14/2016
HealthSURETY BOND - SECURITY OF PERSONAL FUNDS216/8/20167/14/2016
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS236/8/20167/14/2016
HealthDEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES236/8/20167/14/2016
HealthREASONABLE ACCOMMODATION OF NEEDS/PREFERENCES216/8/20167/14/2016
HealthRIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE216/8/20167/14/2016
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT216/8/20167/14/2016
HealthCOMPREHENSIVE ASSESSMENT 14 DAYS AFTER ADMIT226/8/20167/14/2016
HealthCOMPREHENSIVE ASSESS AT LEAST EVERY 12 MONTHS216/8/20167/14/2016
HealthQUARTERLY ASSESSMENT AT LEAST EVERY 3 MONTHS226/8/20167/14/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS216/8/20167/14/2016
HealthTREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS216/8/20167/14/2016
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER216/8/20167/14/2016
HealthINCREASE/PREVENT DECREASE IN RANGE OF MOTION226/8/20167/14/2016
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES226/8/20167/14/2016
HealthMAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE216/8/20167/14/2016
HealthSUFFICIENT FLUID TO MAINTAIN HYDRATION216/8/20167/14/2016
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS216/8/20167/14/2016
HealthINFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS216/8/20167/14/2016
HealthSUFFICIENT 24-HR NURSING STAFF PER CARE PLANS226/8/20167/14/2016
HealthFREQUENCY & TIMELINESS OF PHYSICIAN VISIT216/8/20167/14/2016
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS226/8/20167/14/2016
HealthRESIDENT CALL SYSTEM - ROOMS/TOILET/BATH216/8/20167/14/2016
HealthEFFECTIVE ADMINISTRATION/RESIDENT WELL-BEING236/8/20167/14/2016
HealthNURSE AIDE PERFORM REVIEW-12 HR/YR INSERVICE236/8/20167/14/2016
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE216/8/20167/14/2016
HealthQAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS236/8/20167/14/2016
LSCLIFE SAFETY CODE STANDARD216/8/20167/14/2016
LSCLIFE SAFETY CODE STANDARD226/8/20167/14/2016
LSCLIFE SAFETY CODE STANDARD216/8/20167/14/2016
LSCLIFE SAFETY CODE STANDARD226/8/20167/14/2016
LSCLIFE SAFETY CODE STANDARD226/8/20167/14/2016
LSCLIFE SAFETY CODE STANDARD226/8/20167/14/2016
LSCLIFE SAFETY CODE STANDARD226/8/20167/14/2016
HealthOrganization and Administration226/8/20167/14/2016
LSCMeans of Egress - General226/8/20177/14/2017
LSCExit Signage226/8/20177/14/2017
LSCSoiled Linen and Trash Containers226/8/20177/14/2017
LSCElectrical Systems - Other226/8/20177/14/2017
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)216/8/20177/21/2017
LSCStairways and Smokeproof Enclosures226/8/20177/21/2017
LSCDischarge from Exits226/8/20177/21/2017
LSCVertical Openings - Enclosure226/8/20177/21/2017
LSCFire Alarm System - Installation226/8/20177/21/2017
LSCFire Alarm System - Testing and Maintenance226/8/20177/21/2017
LSCSprinkler System - Maintenance and Testing226/8/20177/21/2017
LSCCorridor - Doors226/8/20177/21/2017
HealthCLEAN BED/BATH LINENS IN GOOD CONDITION126/8/20177/28/2017
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES216/8/20177/28/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES226/8/20177/28/2017
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS216/8/20177/28/2017
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION226/8/20177/28/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES217/14/20167/29/2016
LSCSubdivision of Building Spaces - Smoke Barrie226/8/20178/28/2017
LSCElectrical Equipment - Testing and Maintenanc226/8/20178/28/2017
LSCGas Equipment - Cylinder and Container Storag226/8/20178/28/2017
LSCLIFE SAFETY CODE STANDARD226/8/20168/3/2016
LSCHazardous Areas - Enclosure226/8/20179/18/2017
LSCElectrical Equipment - Power Cords and Extens226/8/20179/18/2017
HealthRequirements Before Submitting a Request for126/8/20169/7/2016
HealthRIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES216/8/20169/7/2016
HealthDIGNITY AND RESPECT OF INDIVIDUALITY226/8/20169/7/2016
HealthSERVICES BY QUALIFIED PERSONS/PER CARE PLAN216/8/20169/7/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES316/8/20169/7/2016
LSCLIFE SAFETY CODE STANDARD226/8/20169/7/2016
LSCLIFE SAFETY CODE STANDARD226/8/20169/7/2016