Comprehensive Rehab & Nursing Ctr At Williamsville
Inspection Findings
F-Tag F0635
F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
10:37 AM, the Director of Nursing stated they had just been made aware by the Medical Director that Resident #7 did not have admission orders entered into their electronic medical record and had received no medications since their readmission on [DATE REDACTED]. The Director of Nursing stated depending on the time of admission it was the responsibility of either the unit manager or the nursing supervisor to enter admission orders from the discharge summary into the electronic medical record and notify the on-call provider to review, confirm and sign all orders. The Director of Nursing stated they would expect admission orders to be entered into the electronic medical record on the day of admission to ensure medications were received and administered timely and avoid any delays or adverse effects. The Director of Nursing stated Resident #7's admission orders should have been entered into the electronic medical record by the nursing supervisor on 09/08/2025.During a telephone interview on 09/10/2025 at 12:24 PM, Licensed Practical Nurse #2 stated they worked on 09/09/2025 from 7:00 AM until 7:00 PM and did not remember administering any medications to Resident #7. They stated other staff members had informed them Resident #7 had just returned from the hospital and their electronic medical record did not show any medications were due to be administered. They stated the Unit Manager or Nursing Supervisor were responsible for completing admission orders. Licensed Practical Nurse #2 stated if a resident was due for a medication or treatment their name would show up in the electronic medication administration record (EMAR) and would be either yellow meaning a medication was due or red indicating a medication was overdue. Licensed Practical Nurse #2 stated they were not familiar with Resident #7's routine medications, and they did not request any medications during their shift. They stated they just assumed no medications were due to be administered during their shift for Resident #7.During an interview on 09/10/2025 at 11:08 AM, Physician Assistant #1 stated the nursing staff would notify them when a new admission arrived at the facility to confirm and sign admission orders after they had been entered into the electronic medical record.
They stated they were the on-call provider on 09/08/2025 and were not notified to review admission orders for Resident #7 upon readmission. Physician Assistant #1 stated on 09/09/2025 they had reviewed Resident #7's hospital discharge summary with Licensed Practical Nurse Unit Manager #1 but no orders had been electronically sent to them to be confirmed and signed. They stated they had just been made aware that Resident #7's admission orders had not been entered into the electronic medical record and
they had not received their medications. Physician Assistant #1 stated Resident #7's missed doses of medications were not medically dangerous but could have exacerbated their anxiety symptoms. They stated the delay in entering admission orders into the electronic medical record was unacceptable.During a telephone interview on 09/10/2025 at 11:28 AM, the Medical Director stated they expected the nursing staff to notify them or the on-call provider when an admission arrived, they would review and electronically sign admission orders after they had been entered by nursing staff. The Medical Director stated they had just been notified Resident #7 readmitted to the facility on [DATE REDACTED] and their admission orders had not been entered into the electronic medical record. They stated they would expect admission orders be entered into
the electronic medical record on the same day of admission to ensure timely administration.10 NYCRR 415.11
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COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE in WILLIAMSVILLE, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WILLIAMSVILLE, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COMPREHENSIVE REHAB & NURSING CTR AT WILLIAMSVILLE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.