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
Staffing
Hours and turnover
RN hours / resident day
1.02
Registered nurse staffing
LPN hours / resident day
0.58
Licensed practical nurse staffing
Aide hours / resident day
1.79
Nurse aide staffing
Weekend hours
2.80
Weekend nurse staffing
RN turnover
35%
Annual RN turnover
Total nurse turnover
54%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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#3
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