Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Comprehensive Rehabilitation and Nursing Center at
WILLIAMSVILLE, NY · 142 certified beds · Last Life Safety survey February 5, 2026
CMS Certification Number 335172 · first certified January 1967
Ownership
Operated by EPHRAM LAHASKY · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
72
Citations on file
Rolling three-year window
4
Life Safety surveys
In the same window
24
Tags cited more than once
Across separate surveys
22
Inspection & testing records
Of the citations on file
Position within NY
72 citations — more than 100% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
Improvingfewer citations at the latest survey than at its earlier surveys in the window.
The latest survey found 2 citations; the earlier surveys in the window averaged 23.3. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens July 2027 — about 10 months from now. This facility’s last Life Safety survey was February 2026. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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8 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
13 of the 72 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
13 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 72 Life Safety citations above. The Physical Environment Index
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0908 Keep all essential equipment working safely.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 72 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 27, 2021 | 17 |
| April 21, 2023 | 31 |
| December 6, 2024 | 22 |
| February 5, 2026 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | 3 | 2024-12-06 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2024-12-06 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2024-12-06 |
| K-0324 | Provide properly protected cooking facilities. | 3 | 2024-12-06 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 3 | 2026-02-05 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-12-06 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2024-12-06 |
| K-0923 | Have proper medical gas storage and administration areas. | 3 | 2024-12-06 |
What the citations cover
- Smoke Deficiencies 23
- Egress Deficiencies 17
- Emergency Preparedness Deficiencies 13
- Gas, Vacuum, and Electrical Systems Deficiencies 12
- Other 7
| Category | Citations |
|---|---|
| Smoke Deficiencies | 23 |
| Egress Deficiencies | 17 |
| Emergency Preparedness Deficiencies | 13 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 12 |
| Miscellaneous Deficiencies | 5 |
| Construction Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 5, 2026 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (April 6, 2026) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (April 6, 2026) |
December 6, 2024 — 22 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (January 24, 2025) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (January 24, 2025) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (January 24, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (January 24, 2025) |
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (January 24, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (February 1, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 20, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (January 31, 2025) |
April 21, 2023 — 31 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (June 20, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (June 20, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 20, 2023) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Waiver has been granted |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Waiver has been granted |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Waiver has been granted |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Waiver has been granted |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (August 4, 2023) |
August 27, 2021 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (October 7, 2021) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (October 7, 2021) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (October 7, 2021) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (October 7, 2021) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (October 7, 2021) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (October 7, 2021) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 18, 2021) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (November 18, 2021) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (November 18, 2021) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 18, 2021) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 7, 2021) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (November 18, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 18, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 18, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 7, 2021) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (October 7, 2021) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 18, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.