Comprehensive Rehabilitation and Nursing Center at Williamsville

Comprehensive Rehabilitation and Nursing Center at Williamsville

147 Reist Street

Williamsville, NY 14221

(716) 633-5400

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: 93%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain22.379036/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened1.328376/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine56.906076/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine64.015156/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication5.50666/1/2017
471Percentage of short-stay residents who made improvements in function70.897536/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased23.393317006/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain6.055422006/1/2017
403Percentage of high risk long-stay residents with pressure ulcers5.167174006/1/2017
404Percentage of long-stay residents who lose too much weight6.954438006/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder66.883116006/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder3.221041006/1/2017
407Percentage of long-stay residents with a urinary tract infection3.597120006/1/2017
408Percentage of long-stay residents who have depressive symptoms1.033593006/1/2017
409Percentage of long-stay residents who were physically restrained0.238663006/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury5.966586006/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine79.487180006/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine69.212409006/1/2017
419Percentage of long-stay residents who received an antipsychotic medication12.244898006/1/2017
451Percentage of long-stay residents whose ability to move independently worsened33.009807006/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication16.499998006/1/2017

Complaints

Number of Standard Health Deficiencies:103
Number of Live Safety Code Deficiencies:40
Number of Total Deficiencies:143
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):98
Intakes received per 100 occupied beds (last three years):75.5
Percent of total intakes received that were facility self reported incidents (last three years):29
On-site complaint investigations (last three years):36
Complaint investigations resulting in citations (last three years):40
Complaint investigations resulting in citations per 100 occupied beds (last three years):30.8
Complaint Citations in deficiency category: Administration:2
Complaint Citations in deficiency category: Quality of Care:21
Complaint Citations in deficiency category: Resident Rights:12
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):40

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
7/14/2016Complaint2
8/20/2015Certification3

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate citation corrected
LSCAUTOMATIC SPRINKLER SYSTEM221/21/2014
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN211/31/2014
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.211/31/2014
LSCGENERATORS INSPECTED/TESTED221/31/2014
LSCTESTING OF FIRE ALARM221/31/2014
LSCSMOKE PARTITION CONSTRUCTION221/31/2014
LSCSTAIRWAY ENCLOSURES AND VERTICAL SHAFTS221/31/2014
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE211/31/2014
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES211/31/2014
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING211/31/2014
LSCSTAIRS AND SMOKE PROOF TOWERS2110/20/2015
HealthRESIDENT RECEIVES NOTICE BEFORE ROOM/ROOMMATE CHANGE2110/20/2015
HealthFOOD IS PREPARED TO MEET INDIVIDUAL NEEDS2110/20/2015
LSCEMERGENCY PLAN2210/20/2015
LSCGENERATORS INSPECTED/TESTED2210/20/2015
HealthCRIMINAL HISTORY RECORD CHECK NOT PERFORMED PROVIDER SHALL SUBMIT REQUEST FOR CHECK2210/20/2015
HealthCRIMINAL HISTORY RECORD CHECK SUBJECT'S SIGNED INFORMED CONSENT REQUIRED2210/20/2015
HealthRANGE OF MOTION TREATMENT AND SERVICES2110/20/2015
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.2110/20/2015
HealthPERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS2110/20/2015
HealthFACILITY RESOLVES RESIDENT GRIEVANCES2210/20/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2110/20/2015
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES2210/20/2015
HealthSUFFICIENT SUPPORT PERSONNEL FOR DIETARY SERVICES2210/20/2015
LSCWASTEBASKETS2110/20/2015
LSCPORTABLE FIRE EXTINGUISHERS2310/20/2015
LSCAUTOMATIC SPRINKLER SYSTEM2210/20/2015
HealthFACILITY PROVIDES DRUGS AND BIOLOGICALS2110/20/2015
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM2110/20/2015
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS2210/20/2015
LSCEXIT SIGNS2210/20/2015
HealthLAB SERVICES ONLY WHEN ORDERED BY PHYSICIAN2110/20/2015
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS2210/20/2015
HealthCRIMINAL HISTORY RECORD CHECK TEMPORARY APPROVAL PENDING RESULTS/ SUPERVISION REQUIRED2210/20/2015
HealthPHYSICAL ENVIRONMENT2210/20/2015
LSCEXIT ACCESS2210/20/2015
LSCFIRE DRILLS2310/20/2015
LSCTESTING OF FIRE ALARM2210/20/2015
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING2110/26/2016
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS2110/26/2016
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE2111/20/2015
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN2211/30/2015
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING2211/30/2015
HealthFACILITY IS FREE OF ACCIDENT HAZARDS2211/30/2015
HealthRESIDENT MAINTAIN NUTRITIONAL STATUS UNLESS UNAVOIDABLE2211/30/2015
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES2211/30/2015
HealthCOMPREHENSIVE ASSESSMENTS2111/30/2015
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS2211/30/2015
HealthRESIDENT DRUG REGIMEN REVIEWED MONTHLY BY PHARMACIST2211/30/2015
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION2111/30/2015
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS2211/30/2015
LSCHAZARDOUS AREAS - SEPARATION2211/30/2015
LSCMEDICAL GAS SYSTEM2211/30/2015
HealthFACILITY MAINTAINS QA COMMITTEE2211/30/2015
HealthSURVEY RESULTS READILY ACCESSIBLE TO RESIDENTS1211/30/2015
HealthPOLICIES, PROCEDURES PROHIBIT ABUSE, NEGLECT2211/30/2015
HealthHOUSEKEEPING AND MAINTENANCE SERVICES2212/13/2015
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES212/13/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS212/13/2015
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN212/13/2015
HealthASSESSMENT AFTER A SIGNIFICANT CHANGE212/13/2015
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE212/13/2015
HealthFACILITY IS FREE OF ACCIDENT HAZARDS212/13/2015
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS222/13/2015
HealthFOOD PROPERLY PREPARED, PALATABLE, ETC.212/13/2015
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS212/13/2015
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS212/13/2015
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM212/13/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS212/13/2015
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION222/13/2015
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING212/13/2015
LSCCORRIDOR DOORS222/13/2015
LSCMEDICAL GAS SYSTEM222/13/2015
LSCDOORS IN FIRE AND SMOKE PARTITIONS222/13/2015
LSCSMOKE PARTITION CONSTRUCTION222/13/2015
LSCHAZARDOUS AREAS - SEPARATION222/13/2015
LSCEXIT SIGNS222/13/2015
LSCTESTING OF FIRE ALARM222/13/2015
LSCAUTOMATIC SPRINKLER SYSTEM222/13/2015
LSCVENTILATING EQUIPMENT222/13/2015
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS212/13/2015
LSCEMERGENCY PLAN222/13/2015
LSCGENERATORS INSPECTED/TESTED222/13/2015
LSCSPACE HEATERS222/13/2015
LSCSPRINKLER SYSTEM MAINTENANCE222/13/2015
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.213/1/2017
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE213/1/2017
HealthMENUS MEET NUTRITIONAL NEEDS/PREPARATION IN ADVANCE/FOLLOWED224/28/2016
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING314/28/2016
HealthRIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES314/28/2016
HealthDIGNITY224/28/2016
HealthPHYSICIAN ORDERS FOR RESIDENT AT TIME OF ADMISSION214/28/2016
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS224/28/2016
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION224/28/2016
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS214/28/2016
HealthHOUSEKEEPING AND MAINTENANCE SERVICES224/28/2016
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION226/29/2015
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE237/14/2016
HealthSURETY BOND OR OTHER ASSURANCE217/14/2016
HealthCRIMINAL HISTORY RECORD CHECK REQUIRED NOTIFICATION TO DOH PER CESSATION OF EMPLOYMENT227/14/2016
HealthDEPARTMENT CRIMINAL HISTORY REVIEW FELONY CHARGES/DIRECT CARE & SUPERVISION PROHIBITED217/14/2016
HealthCRIMINAL HISTORY RECORD CHECK TEMPORARY APPROVAL PENDING RESULTS/ SUPERVISION REQUIRED237/14/2016
HealthFACILITY IS FREE OF ACCIDENT HAZARDS227/14/2016
HealthPOLICIES, PROCEDURES PROHIBIT ABUSE, NEGLECT237/14/2016
HealthACCOMMODATION OF NEEDS AND PREFERENCES217/14/2016
HealthRESIDENT RECEIVES NOTICE BEFORE ROOM/ROOMMATE CHANGE217/14/2016
HealthRESIDENT GIVEN TREATMENT TO IMPROVE/MAINTAIN ADLS217/14/2016
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE217/14/2016
HealthFREQUENCY OF ASSESSMENTS - NO LATER THAN 14 DAYS227/14/2016
HealthASSESSMENT CONDUCTED AT LEAST EVERY 12 MONTHS217/14/2016
HealthQUARTERLY REVIEW OF ASSESSMENTS227/14/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS217/14/2016
HealthCRIMINAL HISTORY RECORD CHECK NOT PERFORMED PROVIDER SHALL SUBMIT REQUEST FOR CHECK237/14/2016
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT217/14/2016
HealthRANGE OF MOTION TREATMENT AND SERVICES227/14/2016
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS217/14/2016
HealthRESIDENT MAINTAIN NUTRITIONAL STATUS UNLESS UNAVOIDABLE217/14/2016
HealthFACILITY MANAGEMENT OF RESIDENT FUNDS217/14/2016
HealthORGANIZATION AND ADMINISTRATION227/14/2016
HealthREGULAR PERFORMANCE REV & INSERVICE OF NURSE AIDES237/14/2016
HealthFACILITY ADMINISTERED EFFECTIVELY TO OBTAIN HIGHEST PRACTICABLE WELL BEING237/14/2016
HealthRESIDENT CALL SYSTEM217/14/2016
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM227/14/2016
HealthFREQUENCY AND TIMELINESS OF PHYSICIAN VISIT217/14/2016
HealthSUFFICIENT NURSING STAFF ON A 24-HOUR BASIS227/14/2016
HealthINFLUENZA AND PNEUMOCOCCAL IMMUNIZATION217/14/2016
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS217/14/2016
HealthFACILITY PROVIDES SUFFICIENT FLUID INTAKE217/14/2016
HealthFACILITY MAINTAINS QA COMMITTEE237/14/2016
LSCDOORS IN SMOKE PARTITIONS217/14/2016
LSCEMERGENCY PLAN227/14/2016
LSCGENERATORS INSPECTED/TESTED227/14/2016
LSCTESTING OF FIRE ALARM227/14/2016
LSCEXIT SIGNS227/14/2016
LSCSTAIRS AND SMOKE PROOF TOWERS217/14/2016
LSCHAZARDOUS AREAS - SEPARATION227/14/2016
HealthFACILITY IS FREE OF ACCIDENT HAZARDS217/29/2016
LSCFIRE DRILLS228/3/2016
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES319/7/2016
HealthCRIMINAL HISTORY RECORD CHECK SUBJECT'S SIGNED INFORMED CONSENT REQUIRED129/7/2016
HealthSERVICES BY QUALIFIED PERSONS IN ACCORDANCE WITH CARE PLAN219/7/2016
HealthFACILITY RESOLVES RESIDENT GRIEVANCES219/7/2016
HealthDIGNITY229/7/2016
LSCSMOKE PARTITION CONSTRUCTION229/7/2016
LSCEXIT ACCESS229/7/2016