Comprehensive Rehabilitation and Nursing Center at Williamsville

Comprehensive Rehabilitation and Nursing Center at Williamsville

147 Reist Street

Williamsville, NY 14221

7166335400

http:www2.erie.gov/saferseniorhomes/index.php?q=comprehensive-rehabilitation-and-nursing-center-williamsville

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: 0%

Occupancy Rate: 65%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine82.53709/1/2020
434Percentage of short-stay residents who newly received an antipsychotic medication4.61109/1/2020
471Percentage of short-stay residents who made improvements in function82.67209/1/2020

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased20.611011/1/2019
404Percentage of long-stay residents who lose too much weight9.023011/1/2019
405Percentage of low risk long-stay residents who lose control of their bowels or bladder55.952011/1/2019
406Percentage of long-stay residents with a catheter inserted and left in their bladder1.572011/1/2019
407Percentage of long-stay residents with a urinary tract infection0.000011/1/2019
408Percentage of long-stay residents who have depressive symptoms2.406011/1/2019
409Percentage of long-stay residents who were physically restrained0.000011/1/2019
410Percentage of long-stay residents experiencing one or more falls with major injury0.980011/1/2019
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine94.363011/1/2019
419Percentage of long-stay residents who received an antipsychotic medication25.263011/1/2019
451Percentage of long-stay residents whose ability to move independently worsened28.605011/1/2019
452Percentage of long-stay residents who received an antianxiety or hypnotic medication15.075011/1/2019

Complaints

Number of Standard Health Deficiencies:52
Number of Live Safety Code Deficiencies:65
Number of Total Deficiencies:117
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):202
Intakes received per 100 occupied beds (last three years):157.2
Percent of total intakes received that were facility self reported incidents (last three years):37
On-site complaint investigations (last three years):47
Complaint investigations resulting in citations (last three years):23
Complaint investigations resulting in citations per 100 occupied beds (last three years):17.9
Complaint Citations in deficiency category: Administration:0
Complaint Citations in deficiency category: Quality of Care:11
Complaint Citations in deficiency category: Resident Rights:3
Complaint Citations in deficiency category: Dietary Services:0
Complaint Citations in deficiency category: Physical Environment:3
Complaint Citations in deficiency category: Other Services:5
Complaint Citations across all deficiency categories (last three years):46

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed
.Multiple Deficiencies12/12/20176000
1/24/2011Quality of Care1/10/20122000
10/16/2018Multiple Deficiencies3/27/20196000
10/28/2010Quality of Care1/18/201210000
2/29/2016Quality of Care6/28/201620000
3/23/2007Quality of Care2/26/20081000
5/20/2020Multiple Deficiencies7/8/202014000
6/8/2016Multiple Deficiencies12/6/201621000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
1/17/2018COMPLAINT2
10/16/2018CERTIFICATION/COMPLAINT2
11/12/2019COMPLAINT2
11/4/2019CERTIFICATION/COMPLAINT3
11/9/2018COMPLAINT2
12/7/2017COMPLAINT2
2/14/2017COMPLAINT2
4/16/2018COMPLAINT2
5/20/2020COMPLAINT2
6/26/2020COMPLAINT2
6/8/2017CERTIFICATION/COMPLAINT4
7/22/2019COMPLAINT2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE2211/9/20181/14/2020
LSCELECTRICAL EQUIPMENT - TESTING AND MAINTENANC2211/9/20181/17/2020
HealthQUALITY OF CARE2211/9/20181/24/2018
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT2211/9/20181/24/2018
HealthQUALITY OF CARE2111/9/20181/24/2018
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER2111/9/20181/24/2018
LSCELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS2211/9/20181/3/2020
LSCEXIT SIGNAGE2211/9/20181/3/2020
LSCFIRE ALARM SYSTEM - TESTING AND MAINTENANCE2211/9/20181/3/2020
LSCPORTABLE FIRE EXTINGUISHERS2211/9/20181/3/2020
LSCSPRINKLER SYSTEM - MAINTENANCE AND TESTING2211/9/20181/3/2020
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES2111/9/201811/30/2018
HealthADMINISTRATION2111/9/201812/14/2018
HealthANTIBIOTIC STEWARDSHIP PROGRAM2111/9/201812/14/2018
HealthBASELINE CARE PLAN2211/9/201812/14/2018
HealthCARE PLAN TIMING AND REVISION2111/9/201812/14/2018
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION2211/9/201812/14/2018
HealthFACILITY ASSESSMENT2111/9/201812/14/2018
HealthINCREASE/PREVENT DECREASE IN ROM/MOBILITY2111/9/201812/14/2018
HealthINFECTION CONTROL2211/9/201812/14/2018
HealthMAINTAINS EFFECTIVE PEST CONTROL PROGRAM2211/9/201812/14/2018
HealthNOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE1211/9/201812/14/2018
HealthPHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS2111/9/201812/14/2018
HealthRESIDENT RIGHTS/EXERCISE OF RIGHTS2111/9/201812/14/2018
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NH1211/9/201812/14/2018
LSCCORRIDOR - DOORS2211/9/201812/14/2018
LSCDOORS WITH SELF-CLOSING DEVICES2211/9/201812/14/2018
LSCEGRESS DOORS2211/9/201812/14/2018
LSCELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS2211/9/201812/14/2018
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE2211/9/201812/14/2018
LSCELECTRICAL SYSTEMS - OTHER2211/9/201812/14/2018
LSCELEVATORS2111/9/201812/14/2018
LSCEXIT SIGNAGE2211/9/201812/14/2018
LSCFIRE ALARM SYSTEM - TESTING AND MAINTENANCE2211/9/201812/14/2018
LSCFIRE DRILLS2211/9/201812/14/2018
LSCFUNDAMENTALS - BUILDING SYSTEM CATEGORIES2211/9/201812/14/2018
LSCGAS EQUIPMENT - CYLINDER AND CONTAINER STORAG2211/9/201812/14/2018
LSCGENERAL REQUIREMENTS - OTHER2211/9/201812/14/2018
LSCHAZARDOUS AREAS - ENCLOSURE2211/9/201812/14/2018
LSCMAINTENANCE, INSPECTION & TESTING - DOORS2211/9/201812/14/2018
LSCMEANS OF EGRESS - GENERAL2211/9/201812/14/2018
LSCPORTABLE FIRE EXTINGUISHERS2211/9/201812/14/2018
LSCSPRINKLER SYSTEM - INSTALLATION2211/9/201812/14/2018
LSCSPRINKLER SYSTEM - MAINTENANCE AND TESTING2211/9/201812/14/2018
LSCSTAIRWAYS AND SMOKEPROOF ENCLOSURES2211/9/201812/14/2018
LSCSUBDIVISION OF BUILDING SPACES - SMOKE BARRIE2211/9/201812/14/2018
LSCSUBDIVISION OF BUILDING SPACES - SMOKE BARRIE2211/9/201812/14/2018
LSCVERTICAL OPENINGS - ENCLOSURE2211/9/201812/14/2018
HealthCARDIO-PULMONARY RESUSCITATION (CPR)2111/9/201812/17/2019
HealthINVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION2111/9/201812/17/2019
HealthREPORTING OF ALLEGED VIOLATIONS2111/9/201812/17/2019
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER2111/9/201812/17/2019
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION2211/9/201812/17/2019
HealthFREE FROM MISAPPROPRIATION/EXPLOITATION2111/9/201812/17/2019
LSCDOORS WITH SELF-CLOSING DEVICES2211/9/201812/17/2019
LSCEGRESS DOORS2211/9/201812/17/2019
LSCELECTRICAL SYSTEMS - OTHER2211/9/201812/17/2019
LSCFIRE DRILLS2211/9/201812/17/2019
LSCGAS EQUIPMENT - CYLINDER AND CONTAINER STORAG2211/9/201812/17/2019
LSCILLUMINATION OF MEANS OF EGRESS2211/9/201812/17/2019
LSCMEANS OF EGRESS - GENERAL2211/9/201812/17/2019
LSCPORTABLE SPACE HEATERS2111/9/201812/17/2019
LSCSTAIRWAYS AND SMOKEPROOF ENCLOSURES2211/9/201812/17/2019
HealthACTIVITIES MEET INTEREST/NEEDS EACH RESIDENT2111/9/201812/22/2019
HealthDEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN2111/9/201812/22/2019
HealthDISCHARGE PLANNING PROCESS2111/9/201812/22/2019
HealthINFECTION CONTROL2211/9/201812/22/2019
HealthQAPI/QAA IMPROVEMENT ACTIVITIES2211/9/201812/22/2019
HealthQUALITY OF LIFE2211/9/201812/22/2019
HealthRESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING2111/9/201812/22/2019
HealthROUTINE/EMERGENCY DENTAL SRVCS IN SNFS2111/9/201812/22/2019
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT1211/9/201812/22/2019
HealthFREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE2111/9/201812/30/2019
HealthINFECTION PREVENTION & CONTROL2211/9/201812/30/2019
LSCALCOHOL BASED HAND RUB DISPENSER (ABHR)2111/9/201812/30/2019
LSCCORRIDOR - DOORS2211/9/201812/30/2019
LSCEP PROGRAM PATIENT POPULATION1311/9/201812/30/2019
LSCFUNDAMENTALS - BUILDING SYSTEM CATEGORIES2211/9/201812/30/2019
LSCHAZARDOUS AREAS - ENCLOSURE2211/9/201812/30/2019
LSCHVAC2211/9/201812/30/2019
LSCLTC AND ICF/IID SHARING PLAN WITH PATIENTS1311/9/201812/30/2019
LSCNAMES AND CONTACT INFORMATION1311/9/201812/30/2019
LSCSUBDIVISION OF BUILDING SPACES - SMOKE BARRIE2211/9/201812/30/2019
LSCSUBSISTENCE NEEDS FOR STAFF AND PATIENTS1311/9/201812/30/2019
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS2111/9/20183/1/2017
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)2111/9/20183/1/2017
HealthBOWEL/BLADDER INCONTINENCE, CATHETER, UTI2111/9/20185/10/2018
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES2111/9/20185/10/2018
HealthQUALITY OF CARE2111/9/20185/10/2018
HealthINFECTION PREVENTION & CONTROL2211/9/20186/29/2020
LSCELECTRICAL SYSTEMS - OTHER2211/9/20187/14/2017
LSCEXIT SIGNAGE2211/9/20187/14/2017
LSCMEANS OF EGRESS - GENERAL2211/9/20187/14/2017
LSCSOILED LINEN AND TRASH CONTAINERS2211/9/20187/14/2017
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)2111/9/20187/21/2017
LSCCORRIDOR - DOORS2211/9/20187/21/2017
LSCDISCHARGE FROM EXITS2211/9/20187/21/2017
LSCFIRE ALARM SYSTEM - INSTALLATION2211/9/20187/21/2017
LSCFIRE ALARM SYSTEM - TESTING AND MAINTENANCE2211/9/20187/21/2017
LSCSPRINKLER SYSTEM - MAINTENANCE AND TESTING2211/9/20187/21/2017
LSCSTAIRWAYS AND SMOKEPROOF ENCLOSURES2211/9/20187/21/2017
LSCVERTICAL OPENINGS - ENCLOSURE2211/9/20187/21/2017
HealthRESIDENT CALL SYSTEM2211/9/20187/22/2020
HealthCLEAN BED/BATH LINENS IN GOOD CONDITION1211/9/20187/28/2017
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS2111/9/20187/28/2017
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION2211/9/20187/28/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES2211/9/20187/28/2017
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES2111/9/20187/28/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES2211/9/20188/15/2019
LSCELECTRICAL EQUIPMENT - TESTING AND MAINTENANC2211/9/20188/28/2017
LSCGAS EQUIPMENT - CYLINDER AND CONTAINER STORAG2211/9/20188/28/2017
LSCSUBDIVISION OF BUILDING SPACES - SMOKE BARRIE2211/9/20188/28/2017
HealthACCURACY OF ASSESSMENTS2111/9/20188/9/2019
HealthINVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION2111/9/20188/9/2019
HealthPROVISION OF MEDICALLY RELATED SOCIAL SERVICE2111/9/20188/9/2019
LSCELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS2211/9/20189/18/2017
LSCHAZARDOUS AREAS - ENCLOSURE2211/9/20189/18/2017