COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE
Open-data reference.
COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE is a for profit - limited liability company facility in WILLIAMSVILLE, NY with 142 certified beds and a 1-star overall CMS rating. The facility has 43 deficiency records on file. Total penalties: $37K.
147 REIST STREET, WILLIAMSVILLE, NY 14221
Phone: 7166335400
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 335172
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 142
- Residents
- 136
- In Hospital
- No
- County
- Erie
- Last Inspection
- Dec 6, 2024
Staffing Data
- RN Hours
- 0.35 (nat'l avg: 0.68)
- LPN Hours
- 1.03
- CNA Hours
- 2.15
- Total Nursing Hours
- 3.53 (nat'l avg: 3.89)
- PT Hours
- 0.12
- Nursing Turnover
- 68.1%
- RN Turnover
- 61.5%
What the CMS Record Reveals About COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE
COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE operates 142 certified beds in WILLIAMSVILLE, NY with approximately 136 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (1★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 43 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $37K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.53 total nursing hours per resident day (national average 3.89), with RN coverage at 0.35 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 68.1%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (43 most recent)
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 4, 2025
Protect each resident from the wrongful use of the resident's belongings or money.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 4, 2025
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 4, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jan 31, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Jan 31, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 31, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 31, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 31, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 31, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 31, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 31, 2025
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jan 31, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Jan 31, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Jan 31, 2025
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Jan 31, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 24, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 15, 2023
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category: Environmental Deficiencies
Corrected: Jun 20, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 6, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Jun 20, 2023
Keep all essential equipment working safely.
Category: Environmental Deficiencies
Corrected: Aug 4, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 20, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Aug 4, 2023
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.
Category: Administration Deficiencies
Corrected: Jun 20, 2023
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 20, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 4, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Jun 20, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jun 20, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 20, 2023
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 20, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 20, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Jun 20, 2023
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category: Resident Rights Deficiencies
Corrected: Mar 30, 2023
Keep all essential equipment working safely.
Category: Environmental Deficiencies
Corrected: Nov 18, 2021
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 7, 2021
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 7, 2021
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.
Category: Pharmacy Service Deficiencies
Corrected: Oct 7, 2021
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 7, 2021
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.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2021
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 7, 2021
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 30, 2021
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.
Category: Resident Rights Deficiencies
Corrected: Oct 7, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 22.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 4.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.4% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 5.3% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 67.8% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 53.8% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 3.5% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 20.1% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 27.5% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 94.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 41.9% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.5% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 24.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 31.5% | Yes |
Penalty History 1 penalties totaling $37K
| Date | Type | Amount |
|---|---|---|
| Jun 21, 2024 | Fine | $37K |
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Frequently Asked Questions
What is the overall CMS rating for COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE?
What are the staffing levels at COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE?
How many beds does COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE have?
Does COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE have any deficiencies on record?
Has COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE received any fines or penalties?
Who owns COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE?
When was COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE last inspected?
What quality measures are tracked for COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.