F
28/100Comprehensive Rehabilitation and Nursing Center at Inspection Report, Violations & Safety Grade (WILLIAMSVILLE, New York)
147 REIST STREET, WILLIAMSVILLE, New York 14221
Phone: 7166335400
CMS Overall:1/5
Overview & Bed Count
Certified Beds
142
Avg Residents/Day
133
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Erie
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing1/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | New York Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.35 | 0.73 | -0.38 |
| Total Nurse Hours per Resident per Day | 2.96 | 3.69 | -0.72 |
| CMS Staffing Rating | 1/5 | 2.9/5 | - |
| Nursing Staff Turnover | 77.4% | 40.3% | - |
Health Citation History
48 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-13 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2026-07-13 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2026-07-13 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2026-07-10 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2026-02-05 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | F – Moderate Harm Potential |
| 2026-01-08 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | E – Moderate Harm Potential |
| 2026-01-08 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-09-15 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from the wrongful use of the resident's belongings or money. | D – Moderate Harm Potential |
| 2025-09-15 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-09-11 | Resident Assessment and Care Planning Deficiencies | Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | D – Moderate Harm Potential |
| 2024-12-06 | Resident Rights Deficiencies | 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. | F – Moderate Harm Potential |
| 2024-12-06 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F – Moderate Harm Potential |
| 2024-12-06 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2024-12-06 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-12-06 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-12-06 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2024-12-06 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-12-06 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D – Moderate Harm Potential |
| 2024-12-06 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-12-06 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | C – Minimal Harm Potential |
| 2024-12-06 | Resident Rights Deficiencies | 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. | B – Minimal Harm Potential |
| 2024-12-06 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | B – Minimal Harm Potential |
| 2024-06-21 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K – Immediate Jeopardy |
| 2023-04-21 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2023-04-21 | Environmental Deficiencies | Keep all essential equipment working safely. | E – Moderate Harm Potential |
| 2023-04-21 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | E – Moderate Harm Potential |
| 2023-04-21 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-04-21 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2023-04-21 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2023-04-21 | Quality of Life and Care Deficiencies | Provide activities to meet all resident's needs. | D – Moderate Harm Potential |
| 2023-04-21 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2023-04-21 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2023-04-21 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-04-21 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | D – Moderate Harm Potential |
| 2023-04-21 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | D – Moderate Harm Potential |
| 2023-04-21 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2023-04-21 | Administration Deficiencies | 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. | C – Minimal Harm Potential |
| 2023-04-21 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | B – Minimal Harm Potential |
| 2021-08-27 | Quality of Life and Care Deficiencies | 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. | E – Moderate Harm Potential |
| 2021-08-27 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2021-08-27 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2021-08-27 | Environmental Deficiencies | Keep all essential equipment working safely. | E – Moderate Harm Potential |
| 2021-08-27 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2021-08-27 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2021-08-27 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2021-08-27 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | D – Moderate Harm Potential |
| 2021-08-27 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2021-08-27 | Resident Rights Deficiencies | 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. | B – Minimal Harm Potential |
Fire Safety Citation History
72 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-02-05 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2026-02-05 | Egress Deficiencies | Meet other general requirements that are deficient. | E – Moderate Harm Potential |
| 2024-12-06 | Egress Deficiencies | Meet other general requirements. | E – Moderate Harm Potential |
| 2024-12-06 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E – Moderate Harm Potential |
| 2024-12-06 | Egress Deficiencies | Install proper backup exit lighting. | E – Moderate Harm Potential |
| 2024-12-06 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2024-12-06 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2024-12-06 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2024-12-06 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2024-12-06 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2024-12-06 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | E – Moderate Harm Potential |
| 2024-12-06 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | E – Moderate Harm Potential |
| 2024-12-06 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | E – Moderate Harm Potential |
| 2024-12-06 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
| 2024-12-06 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2024-12-06 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2024-12-06 | Egress Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-12-06 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2024-12-06 | Smoke Deficiencies | Have properly installed hallway dispensers for alcohol-based hand rub. | D – Moderate Harm Potential |
| 2024-12-06 | Miscellaneous Deficiencies | Have restrictions on the use of portable space heaters. | D – Moderate Harm Potential |
| 2024-12-06 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | C – Minimal Harm Potential |
| 2024-12-06 | Emergency Preparedness Deficiencies | Establish policies and procedures for sheltering. | C – Minimal Harm Potential |
| 2024-12-06 | Emergency Preparedness Deficiencies | Establish policies and procedures for volunteers. | C – Minimal Harm Potential |
| 2024-12-06 | Emergency Preparedness Deficiencies | Provide family notifications of emergency plan. | C – Minimal Harm Potential |
| 2023-04-21 | Construction Deficiencies | Meet other general requirements. | E – Moderate Harm Potential |
| 2023-04-21 | Egress Deficiencies | Meet other general requirements. | E – Moderate Harm Potential |
| 2023-04-21 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2023-04-21 | Egress Deficiencies | 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. | E – Moderate Harm Potential |
| 2023-04-21 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2023-04-21 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E – Moderate Harm Potential |
| 2023-04-21 | Egress Deficiencies | Have exits that are accessible at all times. | E – Moderate Harm Potential |
| 2023-04-21 | Egress Deficiencies | Install proper backup exit lighting. | E – Moderate Harm Potential |
| 2023-04-21 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Have properly installed hallway dispensers for alcohol-based hand rub. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Properly provide smoke detection systems in areas open to corridors. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Install an approved automatic sprinkler system. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2023-04-21 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2023-04-21 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | E – Moderate Harm Potential |
| 2023-04-21 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | E – Moderate Harm Potential |
| 2023-04-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | E – Moderate Harm Potential |
| 2023-04-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
| 2023-04-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2023-04-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that testing and maintenance of electrical equipment is performed. | E – Moderate Harm Potential |
Showing 50 of 72 citations.
Total Penalties & Fines
$60,658
Total Fine Amount (CMS)
2
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-07-10 | Fine | $23,520 | - |
| 2024-06-21 | Fine | $37,138 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the WILLIAMSVILLE area at no cost.
Find Safe, Vetted Facilities Near WILLIAMSVILLE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.