Citations Summary
Jun 2022 – May 202624 Inspections Conducted
13
No citations found
54% of all inspections
11
Resulted in citations
46% of all inspections
143 Total Citations — state avg: 41
Issued across those 11 inspections
57Standard Health
86Life Safety Code
Severity of Citations
How serious were those 143 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 24 inspections in the current reporting window, 13 found no citations at all; inspectors issued 143 citations in total.
- Of those, 57 were standard health citations (quality of care) and 86 were related to the Life Safety Code (fire protection).
- The state logged 161 complaints about this facility; 35 led to on-site inspections.
- The state has 9 formal enforcement actions (fines or stipulations) on record.
A citation is a rule violation noted by a state inspector. Most are corrected through a plan of correction; the sections below show each citation, its severity, and how the facility compares with the statewide average.
Provider Information
Type
Nursing Home
Operating Certificate
1421308N
County
Erie
Phone
(716) 633-5400
Operated By
Comprehensive Care at Williamsville, LLC (For Profit)
DOH Regional Office
Western NY
Occupancy Rate
96%
Inspection Details
Surveys with Citations Only▼
Life Safety Code Citations
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Protection - Other
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Safe/functional/sanitary/comfortable Environ
Standard Health Citation — quality of care
▼
Standard Health Citations
Discharge Process
Standard Health Citation — quality of care
Responsibilities Of Providers; Required Notif
Standard Health Citation — quality of care
Services Provided Meet Professional Standards
Standard Health Citation — quality of care
▼
Standard Health Citations
Criminal History Record Check Process
Standard Health Citation — quality of care
Free From Misappropriation/exploitation
Standard Health Citation — quality of care
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
▼
Standard Health Citations
Admission Physician Orders For Immediate Care
Standard Health Citation — quality of care
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Bowel/bladder Incontinence, Catheter, Uti
Standard Health Citation — quality of care
Develop/implement Abuse/neglect Policies
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
General Requirements
Standard Health Citation — quality of care
Grievances
Standard Health Citation — quality of care
Increase/prevent Decrease In Rom/mobility
Standard Health Citation — quality of care
Infection Prevention & Control
Standard Health Citation — quality of care
Nutrition/hydration Status Maintenance
Standard Health Citation — quality of care
Other Laws, Codes, Rules And Regulations.
Standard Health Citation — quality of care
Qapi/qaa Improvement Activities
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Self-determination
Standard Health Citation — quality of care
Life Safety Code Citations
Alcohol Based Hand Rub Dispenser (abhr)
Life Safety Code Citation — NFPA requirements
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Corridor - Doors
Life Safety Code Citation — NFPA requirements
Egress Doors
Life Safety Code Citation — NFPA requirements
Electrical Equipment - Power Cords And Extens
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Electrical Systems - Other
Life Safety Code Citation — NFPA requirements
Evacuation And Relocation Plan
Life Safety Code Citation — NFPA requirements
Fire Drills
Life Safety Code Citation — NFPA requirements
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Hazardous Areas - Enclosure
Life Safety Code Citation — NFPA requirements
Illumination Of Means Of Egress
Life Safety Code Citation — NFPA requirements
Ltc And Icf/iid Sharing Plan With Patients
Life Safety Code Citation — NFPA requirements
Means Of Egress Requirements - Other
Life Safety Code Citation — NFPA requirements
Plan Based On All Hazards Risk Assessment
Life Safety Code Citation — NFPA requirements
Policies/procedures For Sheltering In Place
Life Safety Code Citation — NFPA requirements
Policies/procedures-volunteers And Staffing
Life Safety Code Citation — NFPA requirements
Portable Fire Extinguishers
Life Safety Code Citation — NFPA requirements
Portable Space Heaters
Life Safety Code Citation — NFPA requirements
Stairways And Smokeproof Enclosures
Life Safety Code Citation — NFPA requirements
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
▼
Standard Health Citations
Resident Records - Identifiable Information
Standard Health Citation — quality of care
▼
Standard Health Citations
Activities Meet Interest/needs Each Resident
Standard Health Citation — quality of care
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Dispose Garbage And Refuse Properly
Standard Health Citation — quality of care
Drug Regimen Review, Report Irregular, Act On
Standard Health Citation — quality of care
Essential Equipment, Safe Operating Condition
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Infection Prevention & Control
Standard Health Citation — quality of care
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
License/comply W/ Fed/state/locl Law/prof Std
Standard Health Citation — quality of care
Medicaid/medicare Coverage/liability Notice
Standard Health Citation — quality of care
Qapi/qaa Improvement Activities
Standard Health Citation — quality of care
Requirements Before Submitting A Request For
Standard Health Citation — quality of care
Resident Call System
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Life Safety Code Citations
Alcohol Based Hand Rub Dispenser (abhr)
Life Safety Code Citation — NFPA requirements
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Corridors - Construction Of Walls
Life Safety Code Citation — NFPA requirements
Discharge From Exits
Life Safety Code Citation — NFPA requirements
Doors With Self-closing Devices
Life Safety Code Citation — NFPA requirements
Electrical Equipment - Power Cords And Extens
Life Safety Code Citation — NFPA requirements
Electrical Equipment - Testing And Maintenanc
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Electrical Systems - Other
Life Safety Code Citation — NFPA requirements
Ep Testing Requirements
Life Safety Code Citation — NFPA requirements
Ep Training Program
Life Safety Code Citation — NFPA requirements
Evacuation And Relocation Plan
Life Safety Code Citation — NFPA requirements
Exit Signage
Life Safety Code Citation — NFPA requirements
Fire Drills
Life Safety Code Citation — NFPA requirements
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
General Requirements - Other
Life Safety Code Citation — NFPA requirements
Hospital Cah And Ltc Emergency Power
Life Safety Code Citation — NFPA requirements
Illumination Of Means Of Egress
Life Safety Code Citation — NFPA requirements
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Means Of Egress Requirements - Other
Life Safety Code Citation — NFPA requirements
Portable Fire Extinguishers
Life Safety Code Citation — NFPA requirements
Roles Under A Waiver Declared By Secretary
Life Safety Code Citation — NFPA requirements
Smoke Detection
Life Safety Code Citation — NFPA requirements
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Request/refuse/dscntnue Trmnt;formlte Adv Dir
Standard Health Citation — quality of care
▼
Standard Health Citations
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
Severity Scale Reference
Level 0 — No Harm Potential
Level 2 — Minor Potential Harm
Level 3 — Actual Harm
Level 4 — Immediate Jeopardy
Complaints
Jun 2022 – May 2026Above state average. This facility received 132.8 complaints per 100 beds vs. a statewide rate of 57.4. 20 citations resulted from those complaints (16.5 per 100 beds vs. 5.3 statewide).
Total Complaints
161
55,669 statewide
Per 100 Occupied Beds
132.8
57.4 state avg
On-Site Inspections
35
7,566 statewide
Citations Issued
20
16.5 per 100 beds · avg 5.3
Facility-Reported Incidents
34%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 2 |
| Dietary Services | 2 |
| Other Services | 5 |
| Physical Environment | 3 |
| Quality of Care | 3 |
| Resident Rights | 5 |
| Total | 20 |
Enforcement & Fines
Jun 2016 – May 20269 enforcement actions totaling $85,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
June 21, 2024
$2,000
Stipulation & Order #NH-24-077 · Signed November 27, 2024
Reason: Physical Environment
Reason: Physical Environment
April 21, 2023
$2,000
Stipulation & Order #NH-23-083 · Signed September 18, 2023
Reason: Infection Control
Reason: Infection Control
December 13, 2020
$2,000
Stipulation & Order #NH-21-134 · Signed July 9, 2021
Reason: Quality of Care
Reason: Quality of Care
October 7, 2020
$12,000
Stipulation & Order #NH-21-062 · Signed April 1, 2021
Reason: Quality of Care
Reason: Quality of Care
May 20, 2020
$14,000
Stipulation & Order #NH-20-027 · Signed July 8, 2020
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
October 16, 2018
$6,000
Stipulation & Order #NH-19-016 · Signed March 27, 2019
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
June 8, 2016
$21,000
Stipulation & Order #NH-16-208 · Signed December 6, 2016
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
February 29, 2016
$20,000
Stipulation & Order #NH-16-177 · Signed June 28, 2016
Reason: Quality of Care
Reason: Quality of Care
Date not yet available
$6,000
Stipulation & Order #NH-17-063 · Signed December 12, 2017
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies