Cycle 1
Health 2024-12-06 · Fire 2024-12-06
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
22 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Williamsville, NY
Comprehensive Rehab & Nursing Ctr At Williamsville
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
147 Reist Street, Williamsville, NY
(716) 633-5400
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
136
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ephram Lahasky
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
28 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
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
0.35
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,803
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.86
Baseline 22.41% · Performance 21.68% · Measure score 0.86 · Achievement 0 · Improvement 0.86
Healthcare-associated infections
2.77
Baseline 7.87% · Performance 7.01% · Measure score 2.77 · Achievement 2.77 · Improvement 2.52
Total nurse turnover
0
Baseline 75.16% · Performance 76.47% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.35
Baseline 3.97 hours · Performance 4.60 hours · Measure score 5.35 · Achievement 5.35 · Improvement 2.99
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 14.08% · Lower 95% interval 7.77% |
| Discharge to community | 33.11% |
50.57%
17.5 pts worse
|
Worse than the National Rate · Eligible stays 72 · Observed rate 19.44% · Lower 95% interval 21.72% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.3% |
95.27%
2 pts better
|
Numerator 72 · Denominator 74 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 74 |
| Discharge self-care score | 36.96% |
53.69%
16.7 pts worse
|
Numerator 17 · Denominator 46 |
| Discharge mobility score | 52.17% |
50.94%
1.2 pts better
|
Numerator 24 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.35% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 74 · Adjusted rate 1.57% |
| Healthcare-associated infections requiring hospitalization | 7.01% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 0.29% |
8.2%
7.9 pts worse
|
Numerator 1 · Denominator 350 |
| Staff flu vaccination coverage | 33.89% |
42%
8.1 pts worse
|
Numerator 102 · Denominator 301 |
| Discharge function score | 54.35% |
56.45%
2.1 pts worse
|
Numerator 25 · Denominator 46 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 23.68% |
25.2%
1.5 pts worse
|
Numerator 9 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.7
1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.9 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.3
0.5 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 67.8% |
91.2%
23.4 pts worse
|
93.4%
25.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 68.6% · Q3 64.5% · Q4 43.5% · 4Q avg 67.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
95.3%
1.3 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.0%
1 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.8% · Q3 3.7% · Q4 3.5% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.3% |
18.5%
13.2 pts better
|
11.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 7.1% · Q4 8.6% · 4Q avg 5.3% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.1%
1.3 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 7.6% · Q3 3.9% · Q4 1.8% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.5% |
13.5%
14 pts worse
|
19.6%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 28.6% · Q3 25.7% · Q4 23.7% · 4Q avg 27.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.5% |
14.8%
16.7 pts worse
|
16.7%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.8% · Q2 31.7% · Q3 29.2% · Q4 25.6% · 4Q avg 31.5% · 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 | 20.1% |
15.1%
5 pts worse
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 21.2% · Q3 34.1% · Q4 17.2% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.4% |
15.5%
6.9 pts worse
|
14.9%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 18.4% · Q3 33.7% · Q4 24.5% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.6%
0.1 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.8% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.4%
About the same
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 2.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
20.8%
4 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 34.5% · Q3 20.2% · Q4 24.3% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.9%
1.4 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.3% · Q3 8.2% · Q4 4.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.8% |
76.7%
22.9 pts worse
|
81.7%
27.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 55.3% · Q3 42.5% · Q4 39.0% · 4Q avg 53.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.0% |
9.7%
7.3 pts worse
|
12.0%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 19.1% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
1.2%
2.3 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.4% · Q3 1.4% · Q4 4.9% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.9% |
78.8%
36.9 pts worse
|
79.7%
37.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.4% |
20.6%
7.2 pts better
|
23.9%
10.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 14.7% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-21 · Fire 2023-04-21
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
31 fire-safety deficiencies
Top issue: Smoke (11 deficiencies)
Cycle 3
Health 2021-08-27 · Fire 2021-08-27
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-06
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
E · Potential for more than minimal harm
2024-12-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-02-01
E · Potential for more than minimal harm
2024-12-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-20
E · Potential for more than minimal harm
2024-12-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-06
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 2025-01-24
D · Potential for more than minimal harm
2024-12-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-06
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-06
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-01-31
C · Minimal harm
2024-12-06
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2025-01-24
C · Minimal harm
2024-12-06
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-01-24
C · Minimal harm
2024-12-06
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-01-24
C · Minimal harm
2024-12-06
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-01-24
E · Potential for more than minimal harm
2023-04-21
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
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.
Not marked corrected
E · Potential for more than minimal harm
2023-04-21
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
E · Potential for more than minimal harm
2023-04-21
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Not marked corrected
E · Potential for more than minimal harm
2023-04-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Not marked corrected
E · Potential for more than minimal harm
2023-04-21
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Not marked corrected
E · Potential for more than minimal harm
2023-04-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-04
C · Minimal harm
2023-04-21
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-06-20
C · Minimal harm
2023-04-21
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-06-20
C · Minimal harm
2023-04-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-20
C · Minimal harm
2023-04-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-06-20
E · Potential for more than minimal harm
2021-08-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-11-18
E · Potential for more than minimal harm
2021-08-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-11-18
E · Potential for more than minimal harm
2021-08-27
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-11-18
E · Potential for more than minimal harm
2021-08-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-11-18
E · Potential for more than minimal harm
2021-08-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-10-07
E · Potential for more than minimal harm
2021-08-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-18
E · Potential for more than minimal harm
2021-08-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-18
E · Potential for more than minimal harm
2021-08-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-10-07
E · Potential for more than minimal harm
2021-08-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-11-18
D · Potential for more than minimal harm
2021-08-27
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2021-10-07
D · Potential for more than minimal harm
2021-08-27
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-11-18
D · Potential for more than minimal harm
2021-08-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-07
C · Minimal harm
2021-08-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-10-07
C · Minimal harm
2021-08-27
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-10-07
C · Minimal harm
2021-08-27
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-10-07
C · Minimal harm
2021-08-27
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-10-07
C · Minimal harm
2021-08-27
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-10-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-08
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-27
D · Potential for more than minimal harm
2026-01-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-27
D · Potential for more than minimal harm
2025-09-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-11-04
D · Potential for more than minimal harm
2025-09-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-04
D · Potential for more than minimal harm
2025-09-11
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-11-04
F · Potential for more than minimal harm
2024-12-06
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-06
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 2025-01-31
D · Potential for more than minimal harm
2024-12-06
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-06
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 2025-01-31
D · Potential for more than minimal harm
2024-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
C · Minimal harm
2024-12-06
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-01-31
B · Minimal harm
2024-12-06
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-01-31
B · Minimal harm
2024-12-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-01-31
K · Immediate jeopardy
2024-06-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-24
D · Potential for more than minimal harm
2023-08-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-04-21
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 2023-08-04
E · Potential for more than minimal harm
2023-04-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-04-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-04-21
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-04-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-21
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 2023-06-20
D · Potential for more than minimal harm
2023-04-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-04-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-04-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-04-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-04-21
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-04-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-04-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-20
C · Minimal harm
2023-04-21
F836 · Administration Deficiencies
Health
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.
Corrected 2023-06-20
B · Minimal harm
2023-04-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-06-20
E · Potential for more than minimal harm
2021-08-27
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2021-11-18
E · Potential for more than minimal harm
2021-08-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-10-07
E · Potential for more than minimal harm
2021-08-27
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-10-07
E · Potential for more than minimal harm
2021-08-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-11-18
D · Potential for more than minimal harm
2021-08-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-09-30
D · Potential for more than minimal harm
2021-08-27
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 2021-10-07
D · Potential for more than minimal harm
2021-08-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-18
D · Potential for more than minimal harm
2021-08-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2021-10-07
D · Potential for more than minimal harm
2021-08-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-07
B · Minimal harm
2021-08-27
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2021-10-07
Penalties and ownership
What sits behind the stars
$37,138
2024-06-21
Fine
Fine · fine $37,138
Fine
Ownership
Gast, David
5% Or Greater Direct Ownership Interest · Individual
Farkovits, Joshua
5% Or Greater Direct Ownership Interest · Individual
Lahasky, Ephram
5% Or Greater Direct Ownership Interest · Individual
Halper, Sam
5% Or Greater Direct Ownership Interest · Individual
Korngut, Debbie
5% Or Greater Direct Ownership Interest · Individual
Lichtschein, Teresa
5% Or Greater Direct Ownership Interest · Individual
Arem, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Shaffer, Craig
W-2 Managing Employee · Individual
Teitelbaum, Jason
W-2 Managing Employee · Individual
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#3
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2-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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