Deficiency Records for Comprehensive Rehab and Nursing Ctr at Williamsville
Updated as of April 01, 2024
A list of the most recent deficiencies for Comprehensive Rehab and Nursing Ctr at Williamsville. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-14 | 2023-09-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-21 | 2023-08-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-21 | 2023-08-04 | N |
| Keep all essential equipment working safely. | Health | 2023-04-21 | 2023-08-04 | N |
| Meet other general requirements. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-21 | 2023-08-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-21 | 2023-06-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-21 | 2023-06-20 | N |
| Provide activities to meet all resident's needs. | Health | 2023-04-21 | 2023-06-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-21 | 2023-06-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-21 | 2023-06-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-21 | 2023-06-20 | N |
| Dispose of garbage and refuse properly. | Health | 2023-04-21 | 2023-06-20 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-04-21 | 2023-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-21 | 2023-06-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-21 | 2023-06-20 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-04-21 | 2023-06-20 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Meet other general requirements. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-21 | 2023-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-21 | 2023-06-06 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-02-13 | 2023-03-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-28 | 2022-07-18 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-08-27 | 2021-11-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-27 | 2021-11-18 | N |
| Keep all essential equipment working safely. | Health | 2021-08-27 | 2021-11-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-27 | 2021-11-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-08-27 | 2021-11-18 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-08-27 | 2021-11-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-27 | 2021-11-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-08-27 | 2021-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-27 | 2021-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-27 | 2021-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-27 | 2021-11-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-27 | 2021-10-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-27 | 2021-10-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-27 | 2021-10-07 | N |
| Dispose of garbage and refuse properly. | Health | 2021-08-27 | 2021-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-27 | 2021-10-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-27 | 2021-10-07 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-08-27 | 2021-10-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-08-27 | 2021-10-07 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-08-27 | 2021-10-07 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-08-27 | 2021-10-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-27 | 2021-10-07 | N |
| Meet other general requirements. | Fire Safety | 2021-08-27 | 2021-10-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-27 | 2021-10-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-27 | 2021-10-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-08-27 | 2021-10-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-27 | 2021-09-30 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-11-04 | 2020-01-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-04 | 2020-01-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-04 | 2020-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-04 | 2020-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-04 | 2020-01-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-04 | 2020-01-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-04 | 2020-01-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-04 | 2019-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-04 | 2019-12-30 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-11-04 | 2019-12-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-11-04 | 2019-12-30 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-11-04 | 2019-12-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-11-04 | 2019-12-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-11-04 | 2019-12-30 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-11-04 | 2019-12-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-04 | 2019-12-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-04 | 2019-12-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-04 | 2019-12-30 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-11-04 | 2019-12-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-11-04 | 2019-12-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-04 | 2019-12-22 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-11-04 | 2019-12-22 | N |
| Provide activities to meet all resident's needs. | Health | 2019-11-04 | 2019-12-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-04 | 2019-12-22 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-11-04 | 2019-12-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-11-04 | 2019-12-22 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-11-04 | 2019-12-17 | N |
| Keep all essential equipment working safely. | Health | 2019-11-04 | 2019-12-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-04 | 2019-12-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-11-04 | 2019-12-17 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-11-04 | 2019-12-17 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-11-04 | 2019-12-17 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-11-04 | 2019-12-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-04 | 2019-12-17 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-11-04 | 2019-12-17 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-11-04 | 2019-12-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-04 | 2019-12-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-04-21 | Not Fixed | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-04-21 | Not Fixed | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-21 | Not Fixed | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-21 | Not Fixed | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-21 | Not Fixed | N |
