A list of the most recent deficiencies for Williamsville Suburban, L L C. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-24 | 2024-03-04 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-17 | 2023-05-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-17 | 2023-05-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-03-17 | 2023-05-08 | 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 | 2023-03-17 | 2023-05-08 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-03-17 | 2023-05-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-17 | 2023-05-08 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-17 | 2023-05-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-17 | 2023-05-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-17 | 2023-05-08 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-03-17 | 2023-05-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-17 | 2023-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-17 | 2023-05-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-17 | 2023-05-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-17 | 2023-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-17 | 2023-05-01 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-03-17 | 2023-05-01 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-03-17 | 2023-05-01 | 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 | 2023-03-17 | 2023-05-01 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-17 | 2023-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-14 | 2022-02-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-05 | 2021-11-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-05 | 2021-11-22 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-05 | 2021-11-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-05 | 2021-11-22 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-06 | 2021-06-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-06 | 2021-06-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-06 | 2021-06-04 | 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 | 2021-05-06 | 2021-05-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-06 | 2021-05-14 | N |
| Keep all essential equipment working safely. | Health | 2021-05-06 | 2021-05-07 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-04-19 | 2019-06-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-19 | 2019-06-14 | 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 | 2019-04-19 | 2019-06-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-19 | 2019-06-14 | N |
| 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 | 2019-04-19 | 2019-06-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-04-19 | 2019-06-14 | 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 | 2019-04-19 | 2019-06-14 | 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 | 2019-04-19 | 2019-06-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-19 | 2019-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-19 | 2019-06-14 | N |
| Dispose of garbage and refuse properly. | Health | 2019-04-19 | 2019-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-19 | 2019-06-14 | N |
| Keep all essential equipment working safely. | Health | 2019-04-19 | 2019-06-14 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-04-19 | 2019-06-14 | 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 | 2019-04-19 | 2019-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-04-19 | 2019-06-14 | N |
