3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Williamsville, NY
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
2699 Wehrle Drive, Williamsville, NY
(716) 632-3700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
192
Certified beds
Average residents
183
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Mcguire Group
Operator or chain grouping
Approved since
1992-04-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 3 staffing / 5 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
RN hours / resident day
0.45
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.45
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
2.78
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
1,736
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.35
Composite VBP score used to determine payment impact.
Payment multiplier
1.0092
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
8.40
Baseline 21.80% · Performance 17.55% · Measure score 8.40 · Achievement 8.37 · Improvement 8.40
Healthcare-associated infections
8.48
Baseline 6.87% · Performance 5.30% · Measure score 8.48 · Achievement 8.48 · Improvement 7.87
Total nurse turnover
2.93
Baseline 52.60% · Performance 51.69% · Measure score 2.93 · Achievement 2.93 · Improvement 0
Adjusted total nurse staffing
1.93
Baseline 3.49 hours · Performance 3.63 hours · Measure score 1.93 · Achievement 1.93 · Improvement 0.1
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.69% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 264 · Observed rate 9.85% · Lower 95% interval 8.19% |
| Discharge to community | 50.57% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 271 · Observed rate 47.23% · Lower 95% interval 44.96% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.6% |
95.27%
4.3 pts better
|
Numerator 251 · Denominator 252 |
| Falls with major injury | 0.4% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 252 |
| Discharge self-care score | 44.98% |
53.69%
8.7 pts worse
|
Numerator 94 · Denominator 209 |
| Discharge mobility score | 57.89% |
50.94%
7 pts better
|
Numerator 121 · Denominator 209 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 252 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.3% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 152 · Observed rate 2.63% · Lower 95% interval 2.99% |
| Staff COVID-19 vaccination coverage | 1.85% |
8.2%
6.3 pts worse
|
Numerator 5 · Denominator 270 |
| Staff flu vaccination coverage | 33.25% |
42%
8.8 pts worse
|
Numerator 130 · Denominator 391 |
| Discharge function score | 55.5% |
56.45%
1 pts worse
|
Numerator 116 · Denominator 209 |
| Transfer of health information to provider | 88.57% |
95.95%
7.4 pts worse
|
Numerator 31 · Denominator 35 |
| Transfer of health information to patient | 99.47% |
96.28%
3.2 pts better
|
Numerator 189 · Denominator 190 |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 24 · Denominator 144 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.2%
8.6 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.0%
0.7 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.8% · Q3 2.3% · Q4 0.7% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
18.5%
15.7 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.2% · Q3 3.3% · Q4 3.1% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
6.1%
5.5 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.8% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.4% |
13.5%
5.1 pts better
|
19.6%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.4% · Q3 7.3% · Q4 11.6% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
14.8%
0.2 pts worse
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 14.5% · Q3 14.3% · Q4 14.5% · 4Q avg 15.0% · 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 | 10.9% |
15.1%
4.2 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 16.8% · Q3 9.4% · Q4 9.8% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.1% |
15.5%
5.4 pts better
|
14.9%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 20.4% · Q3 5.2% · Q4 7.8% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.6%
1 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 2.0% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.4%
0.6 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 1.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
20.8%
3.3 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 24.0% · Q3 29.9% · Q4 10.7% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
6.9%
0.6 pts better
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 3.3% · Q3 7.3% · Q4 7.6% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
76.7%
22.9 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.4% · Q3 99.1% · Q4 99.8% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
9.7%
1.5 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.5% · Expected 10.3% · 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 0.4% · Q2 0.3% · Q3 0.0% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.8% |
78.8%
10 pts better
|
79.7%
9.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.7% |
20.6%
1.9 pts better
|
23.9%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 17.0% · Expected 21.7% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Meet other general requirements.
Corrected 2024-08-05
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 2024-08-05
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-05
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-05
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-05
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-05
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-05
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-05
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-08-05
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-10-14
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 2022-10-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-14
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-14
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-14
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-14
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-14
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 2022-10-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-06
Inspection history
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-05
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-05
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-14
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 2022-10-14
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-10-14
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Nearby options
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