Cycle 1
Health 2025-01-21 · Fire 2025-01-21
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Williamsville, NY
Elderwood At Williamsville
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
200 Bassett Road, Williamsville, NY
(716) 689-6681
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
164
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elderwood
Operator or chain grouping
Approved since
1971-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
1.02
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.76
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
3.09
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,983
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.58
Baseline 18.33% · Performance 18.85% · Measure score 5.58 · Achievement 5.58 · Improvement 0
Healthcare-associated infections
6.19
Baseline 7.10% · Performance 5.99% · Measure score 6.19 · Achievement 6.19 · Improvement 4.79
Total nurse turnover
0
Baseline 49.42% · Performance 63.53% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.69
Baseline 3.62 hours · Performance 3.27 hours · Measure score 0.69 · Achievement 0.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.07% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 216 · Observed rate 12.5% · Lower 95% interval 9.49% |
| Discharge to community | 34.07% |
50.57%
16.5 pts worse
|
Worse than the National Rate · Eligible stays 223 · Observed rate 29.15% · Lower 95% interval 28.61% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.21% |
95.27%
2.9 pts better
|
Numerator 110 · Denominator 112 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 112 |
| Discharge self-care score | 44.05% |
53.69%
9.6 pts worse
|
Numerator 37 · Denominator 84 |
| Discharge mobility score | 44.05% |
50.94%
6.9 pts worse
|
Numerator 37 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 3 · Denominator 111 · Adjusted rate 3.22% |
| Healthcare-associated infections requiring hospitalization | 5.99% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 3.77% · Lower 95% interval 3.44% |
| Staff COVID-19 vaccination coverage | 12.18% |
8.2%
4 pts better
|
Numerator 33 · Denominator 271 |
| Staff flu vaccination coverage | 34.32% |
42%
7.7 pts worse
|
Numerator 151 · Denominator 440 |
| Discharge function score | 44.05% |
56.45%
12.4 pts worse
|
Numerator 37 · Denominator 84 |
| Transfer of health information to provider | 82.61% |
95.95%
13.3 pts worse
|
Numerator 19 · Denominator 23 |
| Transfer of health information to patient | 93.1% |
96.28%
3.2 pts worse
|
Numerator 54 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 15.87% |
25.2%
9.3 pts worse
|
Numerator 10 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.7 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.3
0.7 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
91.2%
5.9 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 97.5% · Q3 98.3% · Q4 99.2% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
95.3%
3.2 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.0%
0.3 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 4.2% · Q4 3.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
18.5%
18.1 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
6.1%
4.2 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.3% · Q3 0.0% · Q4 2.4% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
13.5%
0.8 pts worse
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 14.9% · Q3 10.3% · Q4 12.0% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
14.8%
2.9 pts better
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 11.4% · Q3 7.1% · Q4 7.1% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.2%
0.6 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.8% · Q4 0.8% · 4Q avg 0.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.2% |
15.1%
3.1 pts worse
|
16.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 20.1% · Q3 11.3% · Q4 14.2% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
15.5%
0.3 pts worse
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 16.8% · Q3 11.0% · Q4 11.9% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.6%
0.1 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 1.3% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.4%
1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.8% |
20.8%
About the same
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 21.7% · Q3 19.1% · Q4 23.4% · 4Q avg 20.8% |
| Percentage of long-stay residents with pressure ulcers | 11.9% |
6.9%
5 pts worse
|
5.1%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 10.3% · Q3 8.5% · Q4 14.6% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.6% |
76.7%
4.1 pts worse
|
81.7%
9.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 63.8% · Q2 69.6% · Q3 79.3% · Q4 77.0% · 4Q avg 72.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
9.7%
2.8 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 7.1% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 1.1% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68.0% |
78.8%
10.8 pts worse
|
79.7%
11.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
20.6%
1.8 pts worse
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 22.3% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-20 · Fire 2022-12-20
9 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-09-23 · Fire 2020-09-23
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-21
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-21
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.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-01-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-01-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-01-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-04-04
C · Minimal harm
2025-01-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-07
E · Potential for more than minimal harm
2022-12-20
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 2023-02-17
E · Potential for more than minimal harm
2022-12-20
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 2023-02-17
E · Potential for more than minimal harm
2022-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-17
E · Potential for more than minimal harm
2022-12-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-17
E · Potential for more than minimal harm
2022-12-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-02-17
D · Potential for more than minimal harm
2022-12-20
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-02-17
D · Potential for more than minimal harm
2022-12-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-17
E · Potential for more than minimal harm
2020-09-23
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 2020-11-18
D · Potential for more than minimal harm
2020-09-23
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2020-11-18
D · Potential for more than minimal harm
2020-09-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-11-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-05-01
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 2025-06-20
G · Actual harm
2025-01-21
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 2025-03-07
F · Potential for more than minimal harm
2025-01-21
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-21
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 2025-03-12
D · Potential for more than minimal harm
2025-01-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-21
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 2025-03-12
D · Potential for more than minimal harm
2025-01-21
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 2025-03-12
D · Potential for more than minimal harm
2024-04-23
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 2024-05-23
D · Potential for more than minimal harm
2024-04-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-01-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-05
D · Potential for more than minimal harm
2022-12-20
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 2023-02-17
D · Potential for more than minimal harm
2022-12-20
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 2023-02-17
D · Potential for more than minimal harm
2022-12-20
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-02-17
D · Potential for more than minimal harm
2022-12-20
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 2023-02-17
D · Potential for more than minimal harm
2022-12-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-02-17
D · Potential for more than minimal harm
2022-12-20
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-02-17
D · Potential for more than minimal harm
2022-12-20
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 2023-02-17
D · Potential for more than minimal harm
2020-09-23
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2020-11-18
D · Potential for more than minimal harm
2020-09-23
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 2020-11-18
Penalties and ownership
What sits behind the stars
$75,553
2025-01-21
Fine
Fine · fine $75,553
Fine
Ownership
Cole, Warren
5% Or Greater Direct Ownership Interest · Individual
Rubin, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Cole, Warren
Operational/Managerial Control · Individual
Dirlam, Mark
W-2 Managing Employee · Individual
Rubin, Jeffrey
Operational/Managerial Control · Individual
Nearby options
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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
#2
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Comprehensive Rehab & Nursing Ctr At Williamsville
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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
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