Cycle 1
Health 2025-01-08 · Fire 2025-01-08
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Williamsville, NY
Canterbury Woods
2-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
725 Renaissance Drive, Williamsville, NY
(716) 929-5800
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
42
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-08-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.97
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
4.57
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,784
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 40.00% · Performance 96.61% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.83
Baseline 4.27 hours · Performance 4.17 hours · Measure score 3.83 · Achievement 3.83 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.74% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 34 · Observed rate 8.82% · Lower 95% interval 6.89% |
| Discharge to community | 47.96% |
50.57%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 42.11% · Lower 95% interval 34.37% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.93% |
8.2%
2.3 pts worse
|
Numerator 8 · Denominator 135 |
| Staff flu vaccination coverage | 19.42% |
42%
22.6 pts worse
|
Numerator 74 · Denominator 381 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.2%
8.1 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
95.3%
About the same
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.0%
2.6 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 2.6% · Q3 2.9% · Q4 9.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.3% |
18.5%
10.2 pts better
|
11.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 10.0% · Q3 12.5% · Q4 3.7% · 4Q avg 8.3% |
| Percentage of long-stay residents who lose too much weight | 13.1% |
6.1%
7 pts worse
|
5.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 16.7% · Q3 15.6% · Q4 7.1% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.0% |
13.5%
14.5 pts worse
|
19.6%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 19.4% · Q3 31.2% · Q4 26.7% · 4Q avg 28.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
14.8%
6.3 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 26.1% · Q3 24.0% · Q4 18.2% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.3% |
15.1%
4.2 pts worse
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
15.5%
2 pts worse
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 18.2% · Q3 20.7% · Q4 12.0% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.3% |
0.6%
4.7 pts worse
|
1.0%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 7.8% · Q3 5.7% · Q4 2.5% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
1.4%
2.1 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.6% · Q3 2.9% · Q4 3.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
20.8%
1.9 pts worse
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 26.7% · Q3 26.9% · Q4 9.4% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 11.5% |
6.9%
4.6 pts worse
|
5.1%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 12.5% · Q3 10.4% · Q4 10.2% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
76.7%
9.8 pts better
|
81.7%
4.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.2% · Q2 87.9% · Q3 92.7% · Q4 80.6% · 4Q avg 86.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.4% |
9.7%
6.7 pts worse
|
12.0%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 13.6% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.2%
1.2 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
78.8%
6.9 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
20.6%
5.3 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 22.7% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-02 · Fire 2023-06-02
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-12-30 · Fire 2021-12-30
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-08
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-02-21
E · Potential for more than minimal harm
2023-06-02
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-18
E · Potential for more than minimal harm
2021-12-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-02-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-21
C · Minimal harm
2025-01-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-02-21
E · Potential for more than minimal harm
2023-06-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-18
D · Potential for more than minimal harm
2021-12-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-02-21
B · Minimal harm
2021-12-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-02-21
Penalties and ownership
What sits behind the stars
Ownership
Episcopal Church Home & Affiliates, Inc.
5% Or Greater Direct Ownership Interest · Organization
Andrysiak, Sabrina
Operational/Managerial Control · Individual
Belter, Paul
Operational/Managerial Control · Individual
Belter, Paul
Corporate Director · Individual
Bodkin, John
Operational/Managerial Control · Individual
Carballada, Gregory
Operational/Managerial Control · Individual
Carballada, Gregory
Corporate Director · Individual
Frederick, Rhonda
Operational/Managerial Control · Individual
Frederick, Rhonda
Corporate Director · Individual
Juliano, James
Operational/Managerial Control · Individual
Juliano, James
Corporate Officer · Individual
Lesinski, Dale
Corporate Director · Individual
Mccarthy, Rich
Corporate Director · Individual
Mohney, Katherine
Operational/Managerial Control · Individual
Mohney, Katherine
Corporate Director · Individual
Rossi, Michael
Operational/Managerial Control · Individual
Rossi, Michael
Corporate Director · Individual
Russ, Arthur
Corporate Director · Individual
Ryan, Anne
Corporate Director · Individual
Salvatore, Carol
Corporate Director · Individual
Speth, Joseph
Operational/Managerial Control · Individual
Speth, Joseph
Corporate Director · Individual
Vasquez, Francisco
Operational/Managerial Control · Individual
Vasquez, Francisco
Corporate Director · Individual
Wallace, Robert
Operational/Managerial Control · Individual
Wallace, Robert
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Elderwood At Williamsville
Williamsville, NY
2-star overall rating with 2-star inspections with $75,553 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Comprehensive Rehab & Nursing Ctr At Williamsville
Williamsville, NY
1-star overall rating with 1-star inspections with $37,138 in total fines with 17 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
#3
Beechwood Homes
Getzville, NY
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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