Williamsville Suburban, L L C
WILLIAMSVILLE SUBURBAN, L L C in WILLIAMSVILLE, NY — inspection on December 22, 2025.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
of Resident room [ROOM NUMBER].
The curtain had a 1 1/2 inch diameter red stain with smaller light
washed.
They stated the tear in the mesh would likely get further damaged in the wash, and if that
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)
335647 12/22/2025
Williamsville Suburban, L L C 193 South Union Road Williamsville, NY 14221
During an observation and interview on 12/22/2025 at 9:38 AM, Resident #9 was in bed and stated they were incontinent and had told Certified Nurse Aide #7 they needed to be changed over an hour ago. Resident #9 stated they had not been given any care or incontinent care yet that morning. At 10:09 AM Resident #9 activated their call bell to request incontinent care again.
During a continual observation on 12/22/2025 from 10:09 AM - 10:35 AM, Resident #9's call bell remained activated.During an observation and interview on 12/22/2025 at 10:35 AM, Certified Nurse Aide #6 entered Resident #9's room, turned off their call bell and exited Resident #9's room.
Certified Nurse Aide #6 stated they worked full time on unit and were somewhat familiar with Resident #9.
They stated Resident #9 does not need to be changed that often and usually has their call bell on to be boosted.
Certified Nurse Aide #6 stated everybody, nurses, and aides, were responsible to answer call bells timely because there could be an emergency.
They stated a call bell should be answered right away if you see or hear it, but sometimes it takes longer, five (5) minutes when aides are in other rooms giving care; and there are only three (3) aides on the unit.
During an observation on 12/22/2025 at 10:42 AM, Certified Nurse Aide #7 and Certified Nurse Aide #8 entered Resident #9's room and completed fecal incontinent care on Resident #9.
During an interview on 12/22/2025 at 11:05 AM, Certified Nurse Aide #7 stated they were assigned, responsible for Resident #9.
They stated they boosted and shut Resident #9's window that morning at 8:00 AM and that Resident #9 requested to be changed.
Certified Nurse Aide #7 stated they did not provide requested incontinent care to Resident #9 at that time.
They stated, Just started down the line and started getting people up.
They stated Resident #9 should not have had to wait to be changed but they were in the middle of getting their get up's (residents who needed to be out of bed) ready for the day.
Certified Nurse Aide #7 stated they try and complete care when requested right then and there but Resident #9 required two (2) 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)
335647 12/22/2025
Williamsville Suburban, L L C 193 South Union Road Williamsville, NY 14221
interview on 12/22/2025 at 1:38 PM, the Director of Nursing stated Registered Nurses were
maintaining, caring for PICC (peripheral inserted central catheter) lines should be obtained upon
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
335647 12/22/2025
Williamsville Suburban, L L C 193 South Union Road Williamsville, NY 14221
PM, the Director of Nursing stated the providers saw residents and put in any new orders or changes
follow up evaluation on Resident #4 after being made aware of their negative statements, and have
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)
335647 12/22/2025
Williamsville Suburban, L L C 193 South Union Road Williamsville, NY 14221
the plate warmer was broken.
They also stated they expected the dietary staff to have meals out on
delivered to the floor.
They stated all staff should help pass trays unless they were proving care at
health and quality of life for residents. 10 NYCRR 415.14 (d)(1)(2)
335647 12/22/2025
Williamsville Suburban, L L C 193 South Union Road Williamsville, NY 14221
Observation in the South Building Main Kitchen on 12/18/2025 at 2:05 PM revealed the following:-No chlorine test strips for use with low-temperature dishwashing machine-As the dishwashing machine was running, the thermometer stayed between 40- and 60-degrees Fahrenheit before, during, and after the cycle At the time of the observation, Dietary Aide #2 stated they did not have any test strips. At the time of the observation, Food Service Supervisor #1 stated they could not locate any test strips.
- Observation in the North Building Main Kitchen on 12/18/2025 at 2:22 PM revealed the
following:-No chlorine test strips for use with low-temperature dishwashing machine-As the dishwashing machine was running, the thermometer closer to the floor was covered in a hard film and could not be read, and the thermometer on the machine read 100 degrees Fahrenheit, neither of the thermometers moved before, during, or after the cycle
During 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
335647 12/22/2025
Williamsville Suburban, L L C 193 South Union Road Williamsville, NY 14221
The Maintenance Director stated they believed the overflowing garbage dumpsters at the North
be shut and the area around garbage dumpsters should be kept clean.
The Administrator stated the
department task.10NYCRR 415.14(h)14-1.150
335647 12/22/2025
Williamsville Suburban, L L C 193 South Union Road Williamsville, NY 14221
for any missing narcotics, so the oncoming nurse should not take the keys without counting.During an
minimal harm 12/18/2025, and they counted and verified medication but did not sign between the double shifts. 10 NYCRR 415.22(a)(1-2)
335647 12/22/2025
Williamsville Suburban, L L C 193 South Union Road Williamsville, NY 14221
10 NYCRR 415.19(a)(1)(b)(4)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.