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: 66%

Occupancy Rate: 92%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine76.960011/1/2019
434Percentage of short-stay residents who newly received an antipsychotic medication3.860011/1/2019
471Percentage of short-stay residents who made improvements in function76.890011/1/2019

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased17.860011/1/2019
404Percentage of long-stay residents who lose too much weight10.290011/1/2019
405Percentage of low risk long-stay residents who lose control of their bowels or bladder46.760011/1/2019
406Percentage of long-stay residents with a catheter inserted and left in their bladder1.530011/1/2019
407Percentage of long-stay residents with a urinary tract infection0.240011/1/2019
408Percentage of long-stay residents who have depressive symptoms1.390011/1/2019
409Percentage of long-stay residents who were physically restrained0.000011/1/2019
410Percentage of long-stay residents experiencing one or more falls with major injury3.150011/1/2019
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine93.460011/1/2019
419Percentage of long-stay residents who received an antipsychotic medication18.650011/1/2019
451Percentage of long-stay residents whose ability to move independently worsened30.850011/1/2019
452Percentage of long-stay residents who received an antianxiety or hypnotic medication15.480011/1/2019

Complaints

Number of Standard Health Deficiencies:99
Number of Live Safety Code Deficiencies:75
Number of Total Deficiencies:174
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):190
Intakes received per 100 occupied beds (last three years):147.8
Percent of total intakes received that were facility self reported incidents (last three years):36
On-site complaint investigations (last three years):51
Complaint investigations resulting in citations (last three years):44
Complaint investigations resulting in citations per 100 occupied beds (last three years):34.2
Complaint Citations in deficiency category: Administration:1
Complaint Citations in deficiency category: Quality of Care:19
Complaint Citations in deficiency category: Resident Rights:8
Complaint Citations in deficiency category: Dietary Services:2
Complaint Citations in deficiency category: Physical Environment:3
Complaint Citations in deficiency category: Other Services:7
Complaint Citations across all deficiency categories (last three years):44

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed
.Multiple Deficiencies12/12/20176000
1/24/2011Quality of Care1/10/20122000
10/28/2010Quality of Care1/18/201210000
2/29/2016Quality of Care6/28/201620000
3/23/2007Quality of Care2/26/20081000
6/8/2016Multiple Deficiencies12/6/201621000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
1/17/2018COMPLAINT2
10/16/2018CERTIFICATION/COMPLAINT2
11/12/2019COMPLAINT1
11/4/2019CERTIFICATION/COMPLAINT1
11/9/2018COMPLAINT2
12/7/2017COMPLAINT2
2/14/2017COMPLAINT2
2/29/2016COMPLAINT2
4/16/2018COMPLAINT2
6/8/2016CERTIFICATION/COMPLAINT4
6/8/2017CERTIFICATION/COMPLAINT4
7/14/2016COMPLAINT2
7/22/2019COMPLAINT2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthCARDIO-PULMONARY RESUSCITATION (CPR)2111/9/2018.
HealthINVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION2111/9/2018.
HealthREPORTING OF ALLEGED VIOLATIONS2111/9/2018.
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER2111/9/2018.
HealthACTIVITIES MEET INTEREST/NEEDS EACH RESIDENT2111/9/2018.
HealthDEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN2111/9/2018.
HealthDISCHARGE PLANNING PROCESS2111/9/2018.
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION2211/9/2018.
HealthFREE FROM MISAPPROPRIATION/EXPLOITATION2111/9/2018.
HealthFREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE2111/9/2018.
HealthINFECTION CONTROL2211/9/2018.
HealthINFECTION PREVENTION & CONTROL2211/9/2018.
HealthQAPI/QAA IMPROVEMENT ACTIVITIES2211/9/2018.
HealthQUALITY OF LIFE2211/9/2018.
HealthRESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING2111/9/2018.
HealthROUTINE/EMERGENCY DENTAL SRVCS IN SNFS2111/9/2018.
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT1211/9/2018.
LSCALCOHOL BASED HAND RUB DISPENSER (ABHR)2111/9/2018.
LSCCORRIDOR - DOORS2211/9/2018.
LSCDOORS WITH SELF-CLOSING DEVICES2211/9/2018.
LSCEGRESS DOORS2211/9/2018.
LSCELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS2211/9/2018.
LSCELECTRICAL EQUIPMENT - TESTING AND MAINTENANC2211/9/2018.
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE2211/9/2018.
LSCELECTRICAL SYSTEMS - OTHER2211/9/2018.
LSCEP PROGRAM PATIENT POPULATION1311/9/2018.
LSCEXIT SIGNAGE2211/9/2018.
LSCFIRE ALARM SYSTEM - TESTING AND MAINTENANCE2211/9/2018.
LSCFIRE DRILLS2211/9/2018.
LSCFUNDAMENTALS - BUILDING SYSTEM CATEGORIES2211/9/2018.
LSCGAS EQUIPMENT - CYLINDER AND CONTAINER STORAG2211/9/2018.
LSCHAZARDOUS AREAS - ENCLOSURE2211/9/2018.
LSCHVAC2211/9/2018.
LSCILLUMINATION OF MEANS OF EGRESS2211/9/2018.
LSCLTC AND ICF/IID SHARING PLAN WITH PATIENTS1311/9/2018.
LSCMEANS OF EGRESS - GENERAL2211/9/2018.
LSCNAMES AND CONTACT INFORMATION1311/9/2018.
LSCPORTABLE FIRE EXTINGUISHERS2211/9/2018.
LSCPORTABLE SPACE HEATERS2111/9/2018.
LSCSPRINKLER SYSTEM - MAINTENANCE AND TESTING2211/9/2018.
LSCSTAIRWAYS AND SMOKEPROOF ENCLOSURES2211/9/2018.
LSCSUBDIVISION OF BUILDING SPACES - SMOKE BARRIE2211/9/2018.
LSCSUBSISTENCE NEEDS FOR STAFF AND PATIENTS1311/9/2018.
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
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS2111/9/201810/26/2016
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING2111/9/201810/26/2016
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
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS2111/9/20183/1/2017
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)2111/9/20183/1/2017
HealthADMISSION PHYSICIAN ORDERS FOR IMMEDIATE CARE2111/9/20184/28/2016
HealthDIGNITY AND RESPECT OF INDIVIDUALITY2211/9/20184/28/2016
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION2211/9/20184/28/2016
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY2211/9/20184/28/2016
HealthHOUSEKEEPING & MAINTENANCE SERVICES2211/9/20184/28/2016
HealthMENUS MEET RES NEEDS/PREP IN ADVANCE/FOLLOWED2211/9/20184/28/2016
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING3111/9/20184/28/2016
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE2111/9/20184/28/2016
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES3111/9/20184/28/2016
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
HealthCOMPREHENSIVE ASSESS AT LEAST EVERY 12 MONTHS2111/9/20187/14/2016
HealthCOMPREHENSIVE ASSESSMENT 14 DAYS AFTER ADMIT2211/9/20187/14/2016
HealthCRIMINAL HISTORY RECORD CHECK PROCESS2311/9/20187/14/2016
HealthCRIMINAL HISTORY RECORD CHECK PROCESS2311/9/20187/14/2016
HealthDEPARTMENT CRIMINAL HISTORY REVIEW2111/9/20187/14/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS2111/9/20187/14/2016
HealthDEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES2311/9/20187/14/2016
HealthEFFECTIVE ADMINISTRATION/RESIDENT WELL-BEING2311/9/20187/14/2016
HealthFACILITY MANAGEMENT OF PERSONAL FUNDS2111/9/20187/14/2016
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES2211/9/20187/14/2016
HealthFREQUENCY & TIMELINESS OF PHYSICIAN VISIT2111/9/20187/14/2016
HealthINCREASE/PREVENT DECREASE IN RANGE OF MOTION2211/9/20187/14/2016
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS2211/9/20187/14/2016
HealthINFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS2111/9/20187/14/2016
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS2311/9/20187/14/2016
HealthMAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE2111/9/20187/14/2016
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER2111/9/20187/14/2016
HealthNURSE AIDE PERFORM REVIEW-12 HR/YR INSERVICE2311/9/20187/14/2016
HealthORGANIZATION AND ADMINISTRATION2211/9/20187/14/2016
HealthQAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS2311/9/20187/14/2016
HealthQUARTERLY ASSESSMENT AT LEAST EVERY 3 MONTHS2211/9/20187/14/2016
HealthREASONABLE ACCOMMODATION OF NEEDS/PREFERENCES2111/9/20187/14/2016
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE2111/9/20187/14/2016
HealthRESIDENT CALL SYSTEM - ROOMS/TOILET/BATH2111/9/20187/14/2016
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS2111/9/20187/14/2016
HealthRESPONSIBILITIES OF PROVIDERS; REQUIRED NOTIF2211/9/20187/14/2016
HealthRIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE2111/9/20187/14/2016
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT2111/9/20187/14/2016
HealthSUFFICIENT 24-HR NURSING STAFF PER CARE PLANS2211/9/20187/14/2016
HealthSUFFICIENT FLUID TO MAINTAIN HYDRATION2111/9/20187/14/2016
HealthSURETY BOND - SECURITY OF PERSONAL FUNDS2111/9/20187/14/2016
HealthTREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS2111/9/20187/14/2016
LSCLIFE SAFETY CODE STANDARD2111/9/20187/14/2016
LSCLIFE SAFETY CODE STANDARD2111/9/20187/14/2016
LSCLIFE SAFETY CODE STANDARD2211/9/20187/14/2016
LSCLIFE SAFETY CODE STANDARD2211/9/20187/14/2016
LSCLIFE SAFETY CODE STANDARD2211/9/20187/14/2016
LSCLIFE SAFETY CODE STANDARD2211/9/20187/14/2016
LSCLIFE SAFETY CODE STANDARD2211/9/20187/14/2016
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
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/DEVICES2111/9/20187/29/2016
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
LSCLIFE SAFETY CODE STANDARD2211/9/20188/3/2016
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
HealthDIGNITY AND RESPECT OF INDIVIDUALITY2211/9/20189/7/2016
HealthREQUIREMENTS BEFORE SUBMITTING A REQUEST FOR1211/9/20189/7/2016
HealthRIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES2111/9/20189/7/2016
HealthSERVICES BY QUALIFIED PERSONS/PER CARE PLAN2111/9/20189/7/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES3111/9/20189/7/2016
LSCLIFE SAFETY CODE STANDARD2211/9/20189/7/2016
LSCLIFE SAFETY CODE STANDARD2211/9/20189/7/2016