Williamsville Suburban, L L C

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

on them, that would be beyond regular cleaning. he Housekeeping Supervisor stated they personally were involved in stripping and waxing floors, but on days with limited staffing, they were pulled in different directions, and other tasks took priority above stripping and waxing floors. The Housekeeping Supervisor stated a Housekeeping Aide cleaned the D Wing shower room in the North Building daily, and they had not personally seen it, but if a chair in the toilet area of the D Wing shower room had feces on it or if soiled linen was on the floor, that would not be homelike. They stated, If I saw that coming to visit my family members, I would be upset. Additionally, the Housekeeping Supervisor stated the facility's stripping and buffing floor machines worked, but not at 100 percent, as the machines were damaged while being using earlier this month. They stated the Administrator was made aware of the condition of the floor machines.During an

interview on 12/19/2025 at 2:30 PM, the Housekeeping Supervisor stated the floor in front of the second floor Nurses' Station in the South Building and the wall baseboards in the corridor of the second floor were gray-tone due to a buildup of wax and dirt, and regular mopping would not get that out. Additionally, at this time, the Housekeeping Supervisor looked at the privacy curtain in the center of Resident room [ROOM NUMBER]. The curtain had a 1 1/2 inch diameter red stain with smaller light tan stains and a tear that was 5 inches long at the top mesh. The Housekeeping Supervisor stated the large stain could be blood and the smaller stains were likely coffee, and the curtain needed to be washed. They stated the tear in the mesh would likely get further damaged in the wash, and if that happened, it would have to be replaced.During an

interview on 12/19/2025 at 2:45 PM, the Administrator stated the Housekeeping Supervisor told them earlier this week that the floor machines had some functions that were not up to 100 percent. The Administrator stated they advised the Housekeeping Supervisor to contact the leasing company, as the machines might still be under a maintenance contract, but they still needed to follow up on this with the Housekeeping Supervisor. The Administrator also stated the first and second floors of the South Building were waxed in October, but an older mop head was used, which left streaks, and a new strip and wax was needed in those areas. Additionally, the Administrator stated a homelike environment was important for the residents, and clean, shiny floors and clean resident areas made for a homelike environment.10 NYCRR 415.5(h)(1)(2)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsville Suburban, L L C

163 South Union Road Williamsville, NY 14221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

assist to be changed and they were assigned 12-13 residents. Additionally, Certified Nurse Aide #7 stated it was important that timely care was provided because of health conditions and skin breakdown. During an

interview on 12/22/2025 at 11:28 AM, Licensed Practical Nurse #3 stated if a resident requested to be changed, the aides know they should change the resident right away to prevent skin breakdown. During an

interview on 12/22/2025 at 1:38 PM, the Director of Nursing stated they would have expected timely, as soon as possible, incontinent care to have been provided to Resident #9, to prevent skin breakdown and dignity issues. 10 NYCRR 415.12 (a) (3)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsville Suburban, L L C

163 South Union Road Williamsville, NY 14221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#3 Supervisor, stated Register Nurses were responsible for the assessment and care of PICC (peripheral inserted central catheter) lines. They stated it was important for the PICC (peripheral inserted central catheter) line to be monitored for signs and symptoms of infection, flushed to maintain patency, checked for blood return, and to ensure dressing was clean, dry and intact. Registered Nurse Supervisor #3 stated a PICC (peripheral inserted central catheter) line dressing change should be completed every week and as needed to maintain the site, to keep clean and inspect insertion site for signs/symptoms of infection. They stated the initial nursing assessment of Resident #8's PICC (peripheral inserted central catheter) line was completed by them on 12/15/2025. Registered Nurse #3, Supervisor, stated the exposed external catheter of the PICC (peripheral inserted central catheter) line should have been measured upon admission and

they should have noticed that the dressing had not been changed since 12/8 but had not, missed it. During

an interview on 12/22/2025 at 1:38 PM, the Director of Nursing stated Registered Nurses were responsible for PICC (peripheral inserted central catheter) line care according to orders for flushing, and dressing changes to prevent infection and maintain functioning. They stated orders for maintaining, caring for PICC (peripheral inserted central catheter) lines should be obtained upon admission. During a telephone

interview on 12/22/2025 at 2:26 PM, Nurse Practitioner #2 stated Resident #8's peripheral inserted central catheter line increased their risk for infection. Nurse Practitioner #2 stated they would expect peripheral inserted central catheter policies to be followed. They stated PICC (peripheral inserted central catheter) lines should be checked at least daily; dressing should be clean, dry, intact, and changed as needed by a Registered Nurse to reduce the risk of infection. They stated they would expect Resident #8's PICC (peripheral inserted central catheter) line to be flushed as ordered, once a shift to maintain patency. 10 NYCRR 415.12

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsville Suburban, L L C

163 South Union Road Williamsville, NY 14221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and they would have expected an evaluation to have been completed. There was a good chunk of time recently that the facility only had one social worker, so things were not communicated correctly, and some things were missed. The Administrator reviewed Nurse Practitioner #1's note from 10/28/2025, stated Nurse Practitioner #1 made a recommendation for Resident #4 to see a psych provider; they would have expected Nurse Practitioner #1 to have put an order in for a psych consult so that nursing could follow up on it. They stated they were not sure why Resident #4 had seen psych prior without an order in place.During an

interview on 12/19/2025 at 1:17 PM, the Director of Nursing stated the providers saw residents and put in any new orders or changes to orders themselves. They expected the providers to update Unit Managers on

the new orders or recommendations. The Director of Nursing stated they would have expected social work to do a follow up evaluation on Resident #4 after being made aware of their negative statements, and have nursing send them out to the hospital if they could not be seen by psych in a timely manner. Additionally,

the Director of Nursing stated they started working in the facility in September, they did not know why there was never an order placed previously for Resident #4 to have a psych consult.During a telephone interview

on 12/19/2025 at 1:57 PM, Nurse Practitioner #1 stated they assessed Resident #4 after they were made aware of the families concerns about the negative statements. They stated the facility did not have a psych provider in house at the time of the family's request, so they did not put an order into the system, but did write a recommendation for Resident #4 to see a psych provider so that when the facility had one, Resident #4 could be seen. Nurse Practitioner #1 stated they were unaware Resident #4 had been seen by the prior psych provider and would have expected the facility to follow through with the previous recommendation to see psych in two (2) weeks if that was the previous recommendation in September 2025. They stated there should have been an order in place already if Resident #4 was being seen by psych. They added, It was an issue they came across at the facility often. Additionally, Nurse Practitioner #1 stated they started Resident #4 on Namenda (medication used to treat Alzheimer's symptoms) because they felt there was a progression of their disease, and they ordered a urinalysis to check for a urinary tract infection. They stated

they did not feel Resident #4 was a harm to themselves or others, or else they would have taken more action right away.During a telephone interview on 12/19/2025 at 2:11 PM, Resident #4 family stated they were concerned with Resident #4's mental health and had requested them to be seen by a psych provider,

the facility never got back to them on the request.10 NYCRR 415.12(f)(1)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsville Suburban, L L C

163 South Union Road Williamsville, NY 14221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

and cold foods below 40 degrees. The Food Service Director stated bacteria could grow, and a resident could get sick, if foods were left out of the safe temperature range for very long. They were unsure of the time frame. They stated the staff should be delivering trays to residents within ten (10) minutes of the food leaving the kitchen. The Food Service Director stated they did not have a functioning plate warmer, but they had requested one from administration. They were aware that residents complained about food temperatures. During an interview on 12/22/2025 at 12:04 PM, the Administrator stated they were aware that residents complained about food temperatures. They stated they had put in a request for a new steam table but were waiting for upper level to approve the purchase. The Administrator stated they were not aware the plate warmer was broken. They also stated they expected the dietary staff to have meals out on time and nursing staff to deliver them timely. During an interview on 12/22/2025 at 1:38 PM, The Director of Nursing stated they expected the nursing staff to pass trays immediately when they were delivered to the floor. They stated all staff should help pass trays unless they were proving care at the time of the meal. The Director of Nursing stated that food temperatures were important for the health and quality of life for residents. 10 NYCRR 415.14 (d)(1)(2)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsville Suburban, L L C

163 South Union Road Williamsville, NY 14221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

an interview on 12/18/2025 at 2:35 PM, the Food Service Director stated without chlorine test strips, they did not know whether the sanitizer level was acceptable. During an interview on 12/19/2025 at 8:50 AM, the Maintenance Director stated they were not made aware of any problems with the thermometers on the dishwashing machines. 14. Observation in the North Building Main Kitchen on 12/19/2025 at 8:30 AM revealed one (1) staff member was working on the tray line without a hair net. During an interview on 12/19/2025 at 10:45 AM, the Food Service Director stated there was not currently a kitchen cleaning schedule, as they found an old kitchen cleaning schedule, but it needed to be reviewed and updated before use. The Food Service Director stated Dietary staff should maintain the nourishment refrigerators on the resident units, including daily restocking, checking for undated or outdated items, and cleaning as needed.

They stated as a general rule, unopened foods could be used until the manufacturer's Best By date. Once foods were opened, they needed to be labeled with the date and used within three (3) days, except for cheese, salad dressings, and mayonnaise, which could be kept longer. They stated sanitizing cloths should be kept soaking in a sanitizer, meats should be thawed in a refrigerator or under running water, and coats should be stored in designated areas with coat hooks. During an interview on 12/19/2025 at 2:45 PM, the Administrator stated kitchen cleanliness had improved with the onboarding of a new Food Service Director, was headed in the right direction, but was not where it needed to be yet. 10 NYCRR 415.14(h)Subpart 14-1: 14-1.40, 14-1.42, 14-1.43, 14-1.44, 14-1.72,14-1.86, 14-1.110, 14-1.115, 14-1.117, 14-1.140, 14-1.160, 14-1.171, 14-1.177, 14-1.180

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsville Suburban, L L C

163 South Union Road Williamsville, NY 14221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Maintenance department had asked the Dietary department for help with this task in the past because the items on the ground appeared to be mostly food related. They stated the area around the garbage dumpsters was currently messy and they would ask the contractors who picked up the garbage to move the dumpsters in order for staff to be able to clean around and under them. The Maintenance Director stated

they believed the overflowing garbage dumpsters at the North Building was likely due to big boxes at the bottom taking up space. During an interview on 12/19/2025 at 10:15 AM, the Administrator stated doors and lids to garbage dumpsters should always be shut and the area around garbage dumpsters should be kept clean. The Administrator stated the ground around the North Building dumpsters needed to be cleaned and that was a Maintenance department task.10NYCRR 415.14(h)14-1.150

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsville Suburban, L L C

163 South Union Road Williamsville, NY 14221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

accountability. They stated the nurses were not always signing the sheets like they should.During an

interview on 12/19/2025 at 2:59 PM, Licensed Practical Nurse #5 stated they always signed between shifts

on the count sheet. They did not know why some were blank but thought it might be from different staff floating to help the unit. They stated that the nurse that was leaving was responsible for any missing narcotics, so the oncoming nurse should not take the keys without counting.During an interview on 12/19/2025 at 1:01 PM, Licensed Practical Nurse #8 stated they worked a double on 12/18/2025, and they counted and verified medication but did not sign between the double shifts. 10 NYCRR 415.22(a)(1-2)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsville Suburban, L L C

163 South Union Road Williamsville, NY 14221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

should be changed, hands washed or sanitized after performing fecal incontinent care. They stated dirty and clean material should not mix for infection control.During an interview on 12/22/2025 at 11:28 AM, Licensed Practical Nurse #3 stated gloves should be removed and hands washed as soon as possible after completing fecal incontinence care to prevent the spread of infection and cross contamination. During an

interview on 12/22/2025 at 1:38 PM, the Director of Nursing stated they expect staff to follow enhanced barrier precautions and wear the appropriate personal protective equipment when providing care to prevent

the spread on infection. They stated gloves should be removed and hand hygiene should be performed between handling something dirty and then clean to prevent cross contamination. 10 NYCRR 415.19(a)(1)(b)(4)

Event ID:

Facility ID:

If continuation sheet