438 Main St, Suite 1200 ◦ Buffalo, NY 14202
175 Walnut St, Suite 1 ◦ Lockport, NY 14094
314 Central Ave, Suite 300 ◦ Dunkirk, NY 14048 (716) 853-3087 www.elderjusticeny.org
Comprehensive Rehabilitation and Nursing at Williamsville: A Profile of A Nursing Home Profile Date: December 9, 2022
Purpose and Overview of the Profile
Every nursing home resident, whether in a nursing home for a short-term (i.e., for rehabilitative services after a hospital stay) or long-term stay, deserves quality care and to be safe from harm, abuse and neglect. As documented throughout this report, we believe actions taken by the ownership group of Comprehensive Rehabilitation and Nursing at Williamsville(“Comprehensive at Williamsville”), such as cutting staff,and failing to correct repeat issues, has adversely impacted resident care. Comprehensive at Williamsville is currently owned/operated by some of the same individuals being sued by the New York State (“NYS”) Attorney General, Leticia James, for years of fraud and resident neglect.1
Nursing home operators have a legal obligation to ensure that every person admitted into their facility is provided the care and quality of life services sufficient to attain and maintain each person’s highest practicable physical, emotional, and psychosocial well-being. While there are nursing homes that do provide quality of care and life services, too many do not. As demonstrated by other nursing homes in Western New York (“WNY”) too often private, for-profit ownership has failed to improve resident safety and quality of care.2 Comprehensive at Williamsville, based on the publicly available information, is no exception to this trend.
Business as usual is not working, and, with an estimated 56% of persons aged 57 to 61 spending at least one night in a nursing home during their lifetimes, things must finally change.3 In order for this to happen, resident rights and operator obligations must be known by residents, their families and representatives. In addition, greater oversight on nursing home industry’s business practices, such as related party transactions, and enforcement must occur.
Our goal in developing these Nursing Home Profiles is to improve the quality of care in WNY nursing homes by (1) providing unbiased information on area facilities and ownership and (2) drawing attention to the need to make changes in how the nursing home industry operates
1 Press Release, NYS Attorney General Letitia James, Attorney General James Sues Orleans County Nursing Home for Years of Fraud and resident Neglect (November 29, 2022) https://ag.ny.gov/press-release/2022/attorney-generaljames-sues-orleans-county-nursing-home-years-fraud-and-resident
2 For example, see Center for Elder Law & Justice, Emerald South: Profile of a Nursing Home, July 13, 2018, available: https://static1.squarespace.com/static/6256c7bc7cb2c0315c0bdf86/t/62cc7c263b01ff6d6be3e12a/1657568299872/E merald-South-Profile-of-a-WNY-Nursing-Home-FINAL.pdf
3 Michael D. Hurd, Pierre‐Carl Michaud & Susann Rohwedder, Distribution of Lifetime Nursing Home Use and of Out-of-Pocket Spending, PROCEEDINGS OF THE NAT’L ACAD. OF SCIENCES (Sept. 2017), https://www.pnas.org/doi/10.1073/pnas.1700618114
With the information in this Profile, it is our goal that residents and community members will gain abetter understanding of hownursinghomesoperate,howto distinguish high performing facilities from those that are low performing, and act to improve quality of care. Patients, residents and advocates need to speak up for the right to receive high quality care and to attain or maintain their highest practicable physical, mental, and psychosocial well-being regardless of income, race, socio-economic status, or connections.4
This Profile draws information from public records regarding important indicators of quality and twonursinghomerankingsystems:thefederal CentersforMedicare&MedicaidServices(“CMS”) Care Compare (“Care Compare”) and the NYS Nursing Home Quality Initiative (“NHQI”).5
This report begins with an overview of WNY nursing homes, and then focuses on one facility, Comprehensive at Williamsville and its ownership, as follows:
Topic Page #
Overview of WNY Nursing Homes 3
Summary of Comprehensive at Williamsville and its indicators of Quality 4
Ownership/Operator History of Comprehensive at Williamsville 5
Overview of CMS Care Compare for Comprehensive at Williamsville 8
Summary of Recent DOH Inspection and Repeat Deficiencies at Comprehensive at Williamsville 10
Summary of Staffing Data for Comprehensive at Williamsville 19
Summary of CMS Quality Measure Data for Comprehensive at Williamsville 22
Summary of NQHI Ranking for Comprehensive at Williamsville 27
Federal and State Enforcement for Comprehensive at Williamsville 28
Summary: The Need to Improve Quality of Care and Quality of Life 30
4 This is the federal nursing home legal standard. For additional information on nursing home regulations and resident rights, visit: http://theconsumervoice.org/ ; https://nursinghome411.org/ ; http://www.justiceinaging.org/nursing-homes/ ; and https://www.elderjusticeny.org/elder-law-learn
5 Public records utilized: NYS Department of Health (DOH) survey visits that report each facility’s compliance with federal minimum health standards as well as fire and safety codes; nursing home-reported staffing levels; quality of care measures; and recent changes, if any, in the approved operators of the nursing home. The two nursing home ranking systems, Care Compare and NHQI share one feature – they process the available performance data from each nursing home and then rank the facilities in 5 tiers, distinguishing higher performing facilities from the lower. Care Compare and NHQI utilize many common factors related to quality of care but place differing weights on those factors. Each draw on unique measures, thus offering two viewpoints on a facility’s performance.
Overview of Western New York Nursing Homes
There are 70 nursing homes in the eight WNY counties with 9,810 certified beds.6 The facilities vary widely in size, from 30 beds to 390.7 The overall occupancy rate for the eight counties is less than 83%. The DOH estimates that four WNY counties (Cattaraugus, Chautauqua, Erie and Niagara) have almost 700 more nursing home beds than are needed to serve the population. The remaining four rural counties (Allegany, Genesee, Orleans and Wyoming) are estimated to have an unmet need of over 400 beds to serve the population.8
Among the 70 nursing homes, some are high performing and others are low performing. The quality of care at any nursing home can change over time. Every facility is required to have an administrator and sufficient staff to provide the care that each resident needs to reach their highest practicable level of functioning. However, the Operator of the facility has the ultimate responsibility for the care provided.9
In the last decade, the operators of WNY nursing homes have changed significantly. The predominant model has moved away from a stand-alone facility with a not-for-profit owner and operator. Publicly owned and operated nursing homes are also on the wane. The new prevailing model features operators having multiple nursing home facilities. Most operations are now run as for-profit businesses.10 43WNYnursinghomesareoperatedbyfor-profit businesses(61%oflocal facilities). By comparison, 22 have not-for-profit operators (31%); 4 operate as county facilities (5%); and 1 is a State-operated Veterans Home.11 Also noteworthy is that investors from outside the area own and operate an increasing number of these facilities.
6 Allegany has 4 nursing homes (361 beds at 91% capacity); Cattaraugus 5 nursing homes (552 beds at 81% capacity); Chautauqua 7 nursing homes (924 beds at 79% capacity); Erie 35 nursing homes (5,568 beds at 84% capacity); Genesee 4 nursing homes (488 beds at 85% capacity); Niagara 10 (1389 beds at 74% capacity); Orleans 3 nursing homes (310 beds at 82% capacity); Wyoming 2 nursing homes (218 beds at 95% capacity). See, e.g. CMS Care Compare Provider Dataset (CMS update October 1, 2022). https://data.cms.gov/providerdata/search?theme=Nursing%20homes%20including%20rehab%20services , last accessed November 29, 2022 (Hereinafter referred to as “CMS Provider October 1, 2022”.)
7 Id.
8 Figures are for 2016. https://www.health.ny.gov/facilities/nursing/rhcf_bed_need_by_county.htm , last accessed November 29, 2022.
9 See i.e., 42 CFR 483.70: a facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The governing body of the facility is responsible for appointing the administrator and refers to individuals such as facility owner(s).
10 Each for-profit facility is separately established as a for-profit Limited Liability Corporation (LLC). In most cases, a separate but related LLC owns the building and real estate. See Joseph E. Casson, Julia McMillen, “Protecting Nursing Home Companies: Limiting Liability Through Corporate Restructuring,” Journal of Health Law, Vol. 36, No. 4 (Fall 2003), http://briuswatch.org/wpcontent/ uploads/2016/06/Casson-J.-Protecting-Nursing-Home-Companies-2003.pdf
11 See CMS Provider October 1, 2022; and NYS Health Data NY, Health Facility General Information https://health.data.ny.gov/Health/Health-Facility-General-Information/vn5v-hh5r/data
Undertheprevailing for-profit model,it appearsthat operators seekto cut costs to maximizeprofit. It is the belief of CELJ and other resident advocates that this is done at the expense of resident safety. Vigilance in compliance and enforcement of nursing home laws and regulations is necessary in order to ensure every individual in WNY (and across the state) receives quality of care. It is a human rights issue when the quality of care and life of human beings suffer for the benefit of for-profit operators.
Summary of Comprehensive at Williamsville and its Indicators of Quality12
Ownership:
Comprehensive at Williamsville is a 142-bed facility located at 147 Reist Street in Williamsville, New York. The facility is a Medicare and Medicaid participant. Comprehensive at Williamsville, LLC, purchased and officially took over operations for the facility in May 2015.13 According to CMS records current ownership is comprised as follows:14
• Ephram Lahasky 19%
• Joshua Farkovits 19%
• David Gast 25%
• Samuel Halper 14%
• Debbie Korngut 12%
• Teresa Lichtschein 8%
• Jeffrey Arem 5%
Prior to 2015, Comprehensive at Williamsville was called St. Francis Nursing Home and was operated by Catholic Health System.
Survey Results:
In the most recent annual survey of Comprehensive at Williamsville, completed on August 27, 2021, the DOH identified 13 health deficiencies, with the maximum severity being E, that equates to no actual harm with potential for more than minimal harm that is not immediate jeopardy and is a pattern. Comprehensive at Williamsville has 2.7 times the amount of health deficiencies compared to the statewide average over the prior 3-year period and has a pattern of repeat violations.15 Comprehensive at Williamsville additionally had 5.4 times the amount of life safety code citations compared to the statewide average during this time.16
12 Each area will be discussed in greater detail in this Profile.
13 NYS Certificate of Need (CON) Document Project #141213-E
14 CMS Provider October 1, 2022; see also CON # 161122-E. CMS rounds up: David Gast (24.5%); Samuel Halper (13.5%); Debbie Korngut (11.5%); Teresa Lichtschein (7.5%).
15 From the period November 1, 2018 through October 31, 2022, Comprehensive at Williamsville received 38 standard health citations (state average 14). https://profiles.health.ny.gov/nursing_home/view/150369#inspections , last accessed November 30, 2022.
16 Id.
Staffing:
Comprehensive at Williamsville has a Care Compare 2-star (out of 5 stars) staffing rating; below average.17 This number is seen as a decrease compared to prior years.
Quality Measures:
Comprehensive at Williamsville has a Care Compare 3-star (out of 5 star) rating for quality measures, which are primarily based on facility self-reported data.18
Ratings:
Care Compare ranks Comprehensive at Williamsville as an overall 1-star facility (out of 5 stars), much below the average. Comprehensive at Williamsville is ranked in the worst quintile for the NYS Nursing Home Quality measure and has ranked the worst since 2016.19
Federal and State Enforcement:
Comprehensive at Williamsville recently agreed to pay state fines due to the violations that occurred in December, 2020 ($2,000), October, 2020 ($12,000) and May, 2020 ($14,000). They were also ordered to pay one federal fine in the last 3 years in August, 2021 ($9,750). These stemmed from various regulatory deficiencies, many of which dealt with their handling of the COVID-19 pandemic inside their facility.
Prior to the pandemic, the largest fine paid by Comprehensive at Williamsville were state fines during June, 2016 for multiple deficiencies ($21,000) and February ,2016 ($20,000) for quality of care.
Ownership Background Through Today
The not-for-profit Catholic Health System owned and operated St. Francis Home of Williamsville (“St. Francis”) for many years. It was reported that St. Francis and two Adult Homes, St. Elizabeth’s Home of Lancaster and St. Vincent’s Home of Dunkirk, were experiencing financial loss. 20 In January, 2014, it was announced that Ephram Lahasky and his partners at Comprehensive Healthcare Management Services LLC21 were buying St. Francis and the two
17 CMS Provider October 1, 2022
18 Id.
19 NYS DOH Nursing Home Quality Initiative:
https://www.health.ny.gov/health_care/medicaid/redesign/nursing_home_quality_initiative.htm
20 Drury, Tracey, “New owner sees promise in Catholic Health nursing homes”, Buffalo Business First, January 17, 2014, https://www.bizjournals.com/buffalo/news/2014/01/17/new-owner-sees-promise-in-catholic.html .
21Ephram Lahasky, Joshua Farkovits, David Gast, Sam Halper
Adult Homes.22 On May 13, 2014, an application for change in ownership for Comprehensive at Williamsville was received by the DOH.23 On December 12, 2014 the ownership change was contingently approved and the official takeover of operations, according to available records, occurred in May, 2015.24
Comprehensive Healthcare Management Services LLC closed on the two Adult Homes25 on March 7, 2016 and renamed them Symphony Manor of Lancaster26 and Symphony Living at Dunkirk.27 In December, 2017, it was reported that Symphony Living at Dunkirk would close, leaving 3 dozen seniors and their families to search for new homes by December 31, 2017.28 The DOH lists Symphony Living at Dunkirk as voluntary closed January 7, 2018.29 Shortly after the purchase of Symphony Manor at Lancaster, the DOH conducted its periodic annual inspection and found serious violations of state minimum standards.30 During its next annual inspection period from April, 2017 to September, 2017, the DOH identified deficiencies that were classified as Immediate Jeopardy/Endangerment, the most serious category.31 On November 15, 2017, a new temporary operator was appointed to run the Adult Home, ending Comprehensive Healthcare Management Services’ control.32 In December, 2017, it was announced that Comprehensive was seeking to sell the adult home.33
22 Drury, Tracey, “New owner sees promise in Catholic Health nursing homes”, Buffalo Business First, January 17, 2014, https://www.bizjournals.com/buffalo/news/2014/01/17/new-owner-sees-promise-in-catholic.html
23 CON Project # 141213-E https://apps.health.ny.gov/facilities/cons/nysecon/ProjectInformation.action
24 Id. With final approval letter sent on April 29, 2015.
25 Adult Homes are known as Adult Care Facilities. Adult Care Facilities provide long-term, non-medical residential services to adults who are substantially unable to live independently due to physical, mental, or other limitations associated with age or other factors. There are multiple types of Adult Care Facilities. For more information; https://www.health.ny.gov/facilities/adult_care/intro.htm.
26 In CELJ obtained documents from the DOH via FOIL request, the sole owner of operations was Ephram Lahasky. Broadway Lancaster Realty, LLC was the owner of the property. Members of Broadway Lancaster Realty, LLC were listed as: Jeffrey Arem (10%), Raphael Lichtschein (22.5%), Joshua Farkovitz (22.5%), Ephram Lahasky (22.5%) and David Gast (22.5%).
27 See, Drury, Tracey, “Catholic Health Completes Sale on 2 Adult Homes”, March 17, 2016, Buffalo Business , March 17, 2016, , https://www.bizjournals.com/buffalo/news/2016/03/17/catholic-health-completes-sale-on-2-adulthomes.html and https://www.bizjournals.com/buffalo/news/2014/05/22/li-nursing-home-operator-confident-onturning-st.html.
28 Drury, Tracy, Shutdown looms for Dunkirk adult home,” Buffalo Business First, December 12, 2017 https://www.bizjournals.com/buffalo/news/2017/12/12/shutdown-looms-for-dunkirk-adult-home.html .
29 https://www.health.ny.gov/facilities/adult_care/docs/acf_do_not_refer_list.pdf . It was also reported that Symphony Living at Dunkirk was closing due to the cost of updating the sprinkler and call bell system. Both of which were a requirement of the purchase of the facility. See “Symphony Living closing doors due to inability to fulfill agreements”, Observer, December 30, 2017, https://www.observertoday.com/news/topstories/2017/12/symphony-living-closing-doors-due-to-inability-to-fulfill-agreements/.
30 For example DOH found on 62 shifts between 4/3/2016 and 5/25/2016 were not covered by any staff qualified to administer basic first aid.; at least 18 residents missed approximately 102 doses of prescribed medications because the medications were not in the facility at the time assistance was scheduled to be provided. DOH Event ID# 2WXV11, June 24, 2016.
31 Upon identification of the Immediate Jeopardy deficiencies, DOH remained at the facility for over 40 days, pending the correction of those deficiencies. DOH Event ID YRBA11, November 14, 2017.
32 Letter dated November 15, 2017, issued to facility residents and family members.
33 Drury, Tracy, “Shutdown looms for Dunkirk adult home,” Buffalo Business First, https://www.bizjournals.com/buffalo/news/2016/03/17/catholic-health-completes-sale-on-2-adult-homes.html
In order to operate a nursing home, the DOH must approve the prospective operator through the Certificate of Need (“CON”) application process.34 The members of Comprehensive Healthcare Management Services LLC filed the CON application to become the new operators of St. Francis, to be renamed Comprehensive Rehabilitation and Nursing Center at Williamsville. The new operators would also hold interest in the company that owned the real estate. The CON stated the facility was currentlyoperatingat aloss dueto excess staffingcosts andthattheproposedmembers would implement staffing reductions where overages existed and renegotiate the labor costs. In addition, the CON details that facility expenses were expected to decline from a reduction in salaries and wages and fringe benefits.35
Comprehensive Healthcare Management Services members:
Ephram “Mordy” Lahasky (33.33% member) has at least 5% or greater ownership interest nationally in 61 nursing homes as detailed in Care Compare.36 This is an under count as Mr. Lahasky has testifiedheownsthreenursinghomesin NYS,several hundred nursinghomesoutside of NYS, that includes approximately 65 homes via his ownership interest in Diversicare.37 It has been reported that he invested in the nursing home business in 2012, through Benjamin Landa, who at the time lead SentosaCare.38 In addition to his nursing home investments, he operates medical transport businesses such as Sinai Transportation, a NYC ambulette company and Emergency Ambulance Service. Mr. Lahasky attempted to purchase 3 nursing homes in Vermont, even removing his name and adding his wife to the list of prospective operators.39
Sam Halper (33.34% member) has at least 5% or greater ownership in 7 nursing homes as detailed in Care Compare.40 As of August 9, 2022, Sam Halper who has a 10% ownership stake in Comprehensivewas indictedonchargedof conspiracyto defraudthe United States as well as other health care related fraud charges with several others.41 Comprehensive Healthcare Management Services, LLC. was named in the superseding indictment. Although this indictment relates to
34 For additional information on the CON process, visit: https://www.health.ny.gov/facilities/cons 35 CON #141213 at page 11 36 CMS Provider October 1, 2022 37 See AG Verified Petition at #40 https://ag.ny.gov/sites/default/files/orleans_nh_petition.pdf 38 See Marketwatch report, March 23, 2022, https://www.marketwatch.com/story/all-you-hear-about-is-the-badstuff-ephram-lahasky-has-a-new-investment-model-for-americas-nursing-homes-regulators-have-questions11648041864
39 See Brouwer, Derek, Investors with Questionable Records Want to Buy Five Vermont Nursing Homes Will the State Let Them?”, Seven Days (Published July 21, 2021, updated December 26, 2021). https://www.sevendaysvt.com/vermont/investors-with-questionable-records-want-to-buy-five-vermont-nursinghomes-will-the-state-let-them/Content?oid=33429007 and “Private Equity Group Drops Bid to Purchase Five Vermont Nursing Homes”, https://www.wehmeyerre.com/private-equity-group-drops-bid-to-purchase-fivevermont-nursing-homes/
40 CMS Provider October 1, 2022
41 Press Release, US Attorney’s Office Western District of Pennsylvania, Five Individuals and Two Nursing Facilities Indicted on Charges of Conspiracy to Defraud the United States and Health Care Fraud, (August 9, 2022). https://www.justice.gov/usao-wdpa/pr/five-individuals-and-two-nursing-facilities-indicted-chargesconspiracy-defraud-united
Halper’s involvement with facilities in Southwestern Pennsylvania, it is important to note that it may impact Comprehensive at Williamsville’s functions following the indictment.42
David Gast (33.33% member) has at least 5% or greater ownership in 13 nursing homes as detailed in Care Compare.43 Like with the other members of Comprehensive Management Services, this is an undercount as he testified he owns more than 40 nursing homes outside of NYS and also owns a share of Diversicare.44
Joshua Farkovits, the fourth member listed in the original CON, has at least 5% or greater ownership interest nationally in 26 nursing homes as detailed in Care Compare. Like with Mr. Lahasky, this is an undercount.45
On March 3, 2016, an application for transfer in ownership was received by the DOH.46 On December 12, 2018 the ownership change was contingently approved and the final public health council letter sent on May 10, 2018.47 As detailed in the CON document, the total purchase price for the 36% transfer of ownership from Lahasky, Farkovitz, Gast, and Halper to Debbie Korngut, Teresa Lichtschein, and Jeffrey Arem was $6. While DOH determined there was no negative information received concerning the character and competence of the added individuals, the CON document details that Meadow Park Rehabilitation and Health Care Center, where Teresa Lichtschein had ownership, incurred a Civil Monetary Penalty of $45,366.75 for immediate jeopardy from an October 19, 2016 inspection. On that inspection, the DOH found deficiencies under Quality of Care Accident-Free Environment, and Administration.48
Overview of CMS Care Compare
Care Compare allows consumers to compare information about nursing homes and other health care providers.49 Care Compare provides information about providers and facilities. Specific to Nursing Homes, CMS created a Five-Star Quality Rating System. This Five-Star rating system is meant to help consumers, their families and caregivers compare nursing homes more easily and to help identify areas about which they may want to ask questions. Care Compare contains detailed quality of care and staffing information, as well as survey results, for all of the Medicare and Medicaid participating nursing homes. Much of the information discussed in this Profile is drawn from the Care Compare databases.
Care Compare shows an Overall rating for each nursing home; between 1 and 5 stars. Nursing homes with 5 stars are considered to have “much above average” quality and nursing homes with
42 Id., see also AG Verified Petition at #39 https://ag.ny.gov/sites/default/files/orleans_nh_petition.pdf 43 CMS Provider October 1, 2022 44 AG Verified Petition at #89 https://ag.ny.gov/sites/default/files/orleans_nh_petition.pdf. 45 AG Verified Petition at #42 https://ag.ny.gov/sites/default/files/orleans_nh_petition.pdf 46 Project # 161122-E https://apps.health.ny.gov/facilities/cons/nysecon/ProjectInformation.action 47 Id. 48 Id. 49 https://www.medicare.gov/care-compare/
1 star are considered to have “much below average” quality. CMS advises consumers to use Care Compare together with other sources of information for the nursing homes, especially including a visit to the nursing home. It is the opinion of CELJ and others that the Five-Star rating system is better at identifying bad nursing homes than it is at identifying good ones.50
In addition to the Overall rating, Care Compare also gives a separate rating for each of the following three measures that determine the Overall rating:51
• Health Inspections – Ratings for the health inspections domain are based on the number, scope and severity of deficiencies identified during the three most recent annual inspection surveys, as well as substantiated findings from the most recent 36 months of complaint investigations and focused infection control surveys. All deficiency findings are weighted by scope and severity. The higher the points score means the worse the facility did on inspection. The health inspections rating also takes into account the number of revisits required to ensure that deficiencies identified during health inspection surveys have been corrected.
• Staffing – Ratings for the staffing domain are based on six measures. This includes three nurse staffing level measures (hours per resident per day) and three measures of staff turnover. The staffing measures are derived from data submitted each quarter through the Payroll-Based Journal (PBJ) System, along with daily resident census derived from Minimum Data Set, Version 3.0 (MDS 3.0) assessments. The nurse staffing level measures are case-mix adjusted. For example, a nursing home with residents who had greater needs would be expected to have more nursing staff compared to a nursing home with lower needs. The turnover measures use six consecutive quarters of PBJ data to define annual turnover for nursing staff and administrators. Once points are assigned for each of the six staffing measures a total score is calculated giving the star rating.
• Quality Measures (QMs) - Ratings for the quality measures are based on performance on 15 of the QMs that are currently posted on the Care Compare website. These include nine longstay measures and six short-stay measures. Note that not all the quality measures that are reported on Care Compare are included in the rating calculations. In addition to an overall quality measure rating, separate QM ratings for short-stay measures and long-stay measures are also reported.
50 See i.e., Phillips, C., Hawes, C., Lieberman, T., Koren, M, “Where should Momma go? Current nursing home performance measurement strategies and a less ambitious approach.” BMC Health Services Research (February 2007)Accessed https://www.researchgate.net/publication/6244110_Where_should_Momma_go_Current_nursing_home_performan ce_measurement_strategies_and_a_less_ambitious_approach See also Elder Justice Newsletter https://nursinghome411.org/news-reports/elder-justice/ ; and https://healthjournalism.org/blog/2016/07/whatquality-measures-can-tell-us-about-nursing-home-ratings/ 51 https://www.cms.gov/medicare/provider-enrollment-andcertification/certificationandcomplianc/downloads/usersguide.pdf
Since taking control over ownership in 2015, the CMS ratings for each of the measures have decreased, as detailed by the below table:
CMS Care Compare Star Rating52
Overall Health Staffing QM(SS/LS)53
2022 1 1 2 2(2/2) 2021 1 1 1 3(4/2)
2020 1 1 2 1(1/2) 2019 1 1 2 1(1/1) 2018 1 1 3 2 2017 1 1 3 3 2016 1 1 1 2 2015 4 2 4 5
2014 5 3 4 5 2013 2 2 3 4
Summary of Recent DOH Survey Visits to Comprehensive at Williamsville
Congress set minimum health and fire safety standards for nursing homes that choose to be part of the Medicare and Medicaid programs. In return for these government payments, nursing homes agree to follow the minimum health and fire safety standards and cooperate with an on-site survey process that is conducted about once a year. The DOH conducts these periodic inspections and investigates complaints about nursing home care filed by residents or others. DOH does not give prior notice to the facility as to when the survey team will arrive.54
CMS calculates a weighted score for each survey health inspection based on the scope and severity of the deficiencies that the DOH identifies. More serious, widespread deficiencies receive more points. If the DOH has to conduct repeat visits to confirm that deficiencies have been corrected, more points are added to the score.55
52 See the table on page 13 of this report for additional details on the data 53 SS= Short Stay; LS=Long Stay 54 For additional information on the survey inspection process visit: https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/SurveyCertificationGenInfo/index.html
55 See CMS Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide (October 2022) https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/Downloads/usersguide.pdf
The below tables show how the points are assigned:
CMS bases the health inspection rating on the relative performance of facilities within a state. The top 10% (with the lowest health inspection weighted scores) in each state receive a health inspection rating of 5 stars. The middle 70% of facilities receive a rating of 2, 3, or 4 stars, with an equal number (~23.33%) in each rating category. The bottom 20% receive a 1-star rating. In calculating the total weighted score, more recent standard surveys are weighted more heavily than earlier surveys with the most recent period (rating cycle 1) being assigned a weighting factor of 1/2, the previous period (rating cycle 2) having a weighting factor of 1/3, and the second prior
period (rating cycle 3) having a weighting factor of 1/6. The individual weighted scores for each cycle are then summed (after including complaint surveys, focused infection control surveys and revisit points) to create the total weighted health inspection score for each facility.
Thenursing homes in ErieCounty arerated as follows: 20%(7 facilities)1-star; 5.71% (2facilities) 2-star; 22.86% (8 facilities) 3-star; 34.29% (12 facilities) 4-star; and 2.86% (1 facility) is 5-star.56 Erie County has one facility on the CMS Special Focus Facility (SFF) List.57
Because CMS bases the health inspection rating on the relative performance of facilities within the state, there will always be nursing homes rated at 1 star in the health inspection rating. Each nursing home has a legal responsibility to abide by the minimum federal standards of participation (i.e., the resident rights and protections standards). As such, the goal of each nursing home should be to meet these standards, meaning the health total points score should be at or close to 0.
The cut point for a 1-star health inspection rating in NYS is >40.667.58 Including the CMS SFF, thereare9nursinghomes in ErieCounty whosetotal points exceed40.667. Therangeis 48-184.33, the average is 82.52, and the median is 62.33.59 Comprehensive at Williamsville has 71.67 total weighted points.
For the most current rating cycle, using the August 27, 2021 annual certification inspection, Comprehensive at Williamsville was cited for 11 health deficiencies for violating federal regulations, a total point score of 78.60 When taking into account state based deficiencies, the total number of deficiencies increases to 13.61
The below table lists the health inspection scores since March 9, 2012, when Comprehensive at Williamsville was still under Catholic Health operations as “St. Francis” to the most recent report on August 27, 2021. August 20, 2015 is the first annual inspection under current ownership. As documented by the data, quality quickly decreased and overall, the private, for-profit ownership, has failed to improve resident safety and quality of care
56 Note: during the COVID-19 pandemic, CMS stopped annual certification inspections. As a result, 8-facilities star rating are based on inspections 2+ years old. None of these 8 facilities have a health inspection rating of 1-star.
Source: CMS Provider October 1, 2022
57 Buffalo Center is the SFF, see https://www.cms.gov/medicare/provider-enrollment-andcertification/certificationandcomplianc/downloads/sfflist.pdf for more information.
58 Five Star state level cut point table (October 2022 Update) https://www.cms.gov/medicare/provider-enrollmentand-certification/certificationandcomplianc/downloads/cutpointstable.pdf
59 CMS Provider October 1, 2022
60 CMS Provider October 1, 2022
61 https://profiles.health.ny.gov/nursing_home/view/150369#inspections
DOH Standard Surveydate Health Deficiencies Including Complaints
Weighted score after revisits
Cycle1 08/27/2021 11 78
Cycle2 11/04/2019 12 56
Cycle3 10/16/2018 17 84 06/08/201762 13 64 06/08/201663 35 428 08/20/201564 30 270
12/18/2014 15 68 12/10/201365 5 20 01/17/201366 3 16 03/09/201267 12 60
While Comprehensive at Williamsville has not been cited at Actual Harm or Immediate Jeopardy over the current three survey cycle period, concerns about quality remain. For example, as detailed below, Comprehensive at Williamsville has a long history of repeat violations since the ownership transfer in 2015. When DOH issues a citation for violation of a regulatory requirement, the facility is supposed to rectify the issue. It is concerning when there are chronic deficienices cited by the DOH for the same regulatory violation.68
While we focus on infection control repeat violations, Comprehensive at Williamsville, based on the DOH annual inspection survey completed on August 27, 2021, was cited for numerous other regulatory violations that were repeat deficiencies from prior annual and complaint inspections. These include:
• F584: Resident’s Right to a Safe, Clean, Comfortable, Homelike Environment. Four citations since acquiring the facility in 2015: 10/28/2021; 11/04/2019; 1/17/2018; 08/20/2015.
• F656: Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. Five citations since acquiring the facility in 2015: 08/27/2021; 11/04/2019; 01/17/2018; 06/08/2016; and 08/20/2015. It
62
CMS Provider 10/01/2019 63 Id. 64
CMS Provider 10/01/2016 65 CMS Provider 10/01/2014 66 Id. 67 Id.
68 For additional information on the issue of chronic deficiencies, see LTCCC’s report, “Chronic Deficiencies in Care. The persistence of Recurring Failures to Meet Minimum Safety & Dignity Standards in U.S. Nursing Homes. 2017. https://nursinghome411.org/wp-content/uploads/2017/02/LTCCC-Report-Nursing-Homes-ChronicDeficiencies-2017.pdf
should be noted that when the facility was owned/operated by Catholic Health System, it was cited for this deficiency on 12/18/2014.
• F688: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Four citations since acquiring the facility in 2015: 08/27/2021; 10/16/2018; 06/08/2016; 08/20/2015
• F908: Maintain all mechanical, electrical, and patient care equipment in safe operating condition. Comprehensive has been cited six times since acquiring the facility in 2015: 08/27/21; 11/14/2019; 10/16/2018; 06/08/207; 08/20/2015 and 06/11/2015. It should be noted that when the facility was owned/operated by Catholic Health System, it was cited for this deficiency on 12/18/2014.
Infection Control: F880
As detailed below, Comprehensive at Williamsville had issues with infection prevention and control prior to the pandemic and arguably because of these issues, set the stage for resident harm during the pandemic. For example, in October of 2021, federal officials sent a strike team to Comprehensive in response to a large COVID-19 outbreak, where 61 residents and staff tested positive for the virus between September 27 and October 17, 2021.69
Earlier in March of 2021, Comprehensive left residents without hot water for days after Legionella bacteria was found in the water.70 Legionelladoes not often affect most healthypeople even ifthey are exposed to it, however Comprehensive’s resident pool is made up of many types of people who are at increased risk of sickness if exposed (those over 50, weakened immune systems or underlying illnesses).71 Processes and procedures must be proper and implemented. Otherwise, resident health and safety may be adversely impacted.
• August 27, 2021
Newly admitted resident was admitted and was not wearing a surgical mask while in the dining room. In addition, the resident’s room door did not have a sign that indicated the resident was on transmission-basedprotocols (TBPs)andthere was noPPEset up onthedoor.During observation, an occupational therapist (OT) was in the resident’s room wearing a surgical mask and no other PPE while in direct contact with the resident. The OT stated they were uncertain of the facility protocols for unvaccinated, newly admitted residents and didn’t know if the resident was on
69 “Williamsville nursing home: 8 people have died from COVID-19”, WGRZ (October 22, 2020, updated October 24, 2020). https://www.wgrz.com/article/news/health/coronavirus/report-federal-officials-visit-williamsvillenursing-home-after-covid-outbreak/71-c5c6607b-01d2-4b23-b3f5-6a557bc4f83c
70 McAndrew, Mike, “Williamsville nursing home without hot water for days after Legionella found in water,” Buffalo News, (March 10, 2021, Updated May 25, 2021). https://buffalonews.com/news/local/williamsville-nursinghome-without-hot-water-for-days-after-legionella-found-in-water/article_9e03c014-81d9-11eb-89c72b8d59df75fb.html
71 For example of the dangerous of Legionnaires in nursing home, see https://www.nbcnewyork.com/news/local/5deaths-at-nyc-nursing-home-blamed-on-legionnaires-disease/3956035/ , where 5 residents died.
precautions. The Director of Nursing was interviewed who stated that the resident was not vaccinated and should have been on precautions since their admission date.
• October 7, 2020 (COVID-19 Focus Survey)72
The facility did not ensure staff were checked for COVID-19 symptoms, including temperature checks every 12 hours while on duty. During interview on 10/7/20 the Administrator told DOH that the facility census was 98 with 49 COVID-19 positive residents who were cohorted on Unit 5. There were 18 staff and four agency staff out of work related to COVID-19 and stated Units One, Two and Six were yellow zones (residents that have been potentially exposed to COVID-19 due to outbreak in the facility).
During an interview on 10/7/20 at 2:17 PM, with Administrator and Infection Preventionist Registered Nurse #1 (IP RN #1) present, IP RN #1 stated they were not aware of the 12-hour screening requirement until today and now they know it is supposed to be done every 12 hours, which they were not doing. The Administrator stated they have a bunch of regular staff that are always willing to help out and work overtime but have not been re-screening or taking temperatures after working 12 hours. The IP RN #1 also stated, when staff come in for the start of their shift they are screened, temperature is taken, and they sign the employee log sheet. They have some staff who pick up extra time and know that staff will be working over eight hours from the start of the shift but they do not get re-screened or re-temped when working over 12 hours
• May 20, 2020 (COVID-19 Focus Survey)
The facility did not practice social distancing on two of four units, residents were not assessed for signs and symptoms of COVID-19 and there was a lack of proper hand hygiene. On May 19, DOH observed Activity Aide #1 was distributing crayons, pencils and paper to the residents sitting at the tables. The nine residents were seated in the same locations, were not wearing face masks and were not social distancing. The Activity Aide made no attempt to redirect or social distance the residents sitting at the tables. During interview on 5/19/20 at 11:26 AM Licensed Practical Nurse (LPN # 4) stated they try to make sure all residents are social distanced. "We try our best."
Observations of Unit 2 on 5/19/20 at 12:44 PM revealed Certified Nurse Aide (CNA) #4 entered a resident's room who was presumed positive for COVID-19 and delivered a meal tray without wearing gloves. CNA #4 exited the room without completing hand hygiene, went to the meal delivery cart parked in the hallway, removed another meal tray from the cart, and entered a resident's room who was non-COVID-19 positive.
CNA #4 exited the non-COVID-19 resident room and did not complete hand hygiene. During interview on 5/19/20 at 12:49 PM, CNA #4 stated the residents on Unit 2 were on precautions
72 Note: while not cited again on a 10/23/20 inspection, the report stated “the facility remains out of substantial compliance related to the 10/7/20 Focused Infection Control Survey.” Event ID: X6QT11
because they were new admissions to the facility and do not have COVID-19. CNA #4 was unaware that she should wash her hands in between delivering meal trays because she "didn't physically touch the patients."
• November 4, 2019
Based on record review and interview conducted during a Standard survey completed on 11/4/19, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease for three (employees A, B and C) of 10 employees reviewed. Specifically, the facility did not provide documented evidence that education was provided to its employees on the risks and benefits of the pneumococcal vaccine. Additionally, the facility did not conduct a Legionella risk assessment, did not have a water management plan in place, did not complete quarterly sampling of the facility's water system and the facility did not report positive legionella water samples that exceeded New York State guidelines. This affected three (Unit 1-2, Unit 5, and Unit 6) of three resident units, one of one Second Floor (administration), and one of one Basement.
• October 8, 201673
Report notes that this is a repeat deficiency from the standard surveys completed on 12/18/14 and 8/20/15. One of four residents observed for infection control practices during personal care had issues involving the lack of proper hand hygiene after providing peri-care and prior to touching items in the environment. In addition, the laundry room observed for infection control had five washing machines with large amounts of sediment on the front of the washing machines; and the facility did not maintain a record of incidence of and corrective actions related to infections.
• August 20, 201574
Report notes that this is a repeat deficiency from the standard survey completed on 12/18/14.75 One of eight residents observed for infection control practices during personal care had issues involving the lack of proper hand hygiene after providing urinary incontinence care and prior to touching items in the environment. In addition, staff placed clean heel booties on the floor. During an interview with the resident’s daughter, she stated “she is always picking up soiled gloves and paper towels from the floor, the garbage cans never have bags and she is always wiping down surfaces. In addition, she does not feel staff wash her mother thoroughly.”
73 Event ID YV1O11
74 Event ID YL1O11
75 On 12/18/2014 Catholic Health Systems was the official operator of the facility. The facility was cited because a staff member that had not received the flu vaccine was not wearing a mask while providing direct resident care. The facility was also cited for the contamination of clean items and resident furniture after performing fecal incontinence care for a resident
The following tables provide a summary of the prior survey reports:
CMS Care Compare76
76 https://www.medicare.gov/care-compare/inspections/nursing-home/335172/health . Last accessed December 2, 2022.
77 https://profiles.health.ny.gov/nursing_home/view/150369#inspections, last accessed December 2, 2022.
Comprehensiveat Williamsville is also citedat highernumbers compared to theNYS andNational average for deficiencies under the Life Safety Code:78
Inspection Date Total # Deficiencies Avg NYS
Avg National
08/27/2021 17 4.3 4.4 11/04/2019 26 3.9 4.4 10/16/2018 23 4.4 4.6
As with the health deficiencies, Comprehensive at Williamsville has a history of repeat violations under the Life Safety Code.79 The following deficiencies were cited in each of the 3 recent annual DOH inspections:
• K211: Keep aisles, corridors, and exits free of obstruction in case of emergency.
• K223: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
• K225: Have stairways and smokeproof enclosures used as exits that meet safety requirements.
• K321: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
• K353: Inspect, test, and maintain automatic sprinkler systems.
• K363: Install corridor and hallway doors that block smoke.
• K918: Have generator or other power source capable of supplying service within 10 seconds.
• K923: Have proper medical gas storage and administration areas.
Staffing
Federal law requires nursing homes provide enough staff to adequately care for residents in order for residents to attain and maintain their highest practicable physical, emotional and social wellbeing. Currently no federal minimum staffing requirements exist for nursing homes. CMS is studying the matter and expects to release proposed federal minimum staffing standards in early 2023.80
Minimum nurse staffing standards exist in NYS.81 Specifically, all nursing homes in NYS must meet these minimum standards:
78 https://www.medicare.gov/care-compare/inspections/nursing-home/335172/fire ; download December 7, 2022
79 CMS Care Compare Fire Safety Deficiencies dataset, October 1, 2022.
80 CMS Staffing Study to Inform Minimum Staffing Requirements for Nursing Homes –https://www.cms.gov/blog/centers-medicare-medicaid-services-staffing-study-inform-minimum-staffingrequirements-nursing-homes
81 NYS PHL 2895-b
• 3.5 hours of care pre resident per day (HPRD) by nursing staff (CNA, LPN, RN)
• 2.2 HPRD by CNA/TNA; and
• 1.1 HPRD RN and LPN
These are minimum average standards. If residents need higher hours of nurse staffing care, both federal and NYS law require the nursing home to provide it.
Section 6106 of the Affordable Care Act requires nursing homes electronically submit direct care staffing information based on payroll and other auditable based data. Nursing homes do this via the Payroll Based Journal (“PBJ”) system. Nursing homes have been required to submit this information through the PBJ since January 1, 2016.82
Comprehensive at Williamsville did, on average, for Quarter 1 2022 PBJ data, meet the minimum NYS standards for total HPRD for total nursing staff (CNA, LPN, RN) at 3.69, RN and LPN at 1.35, and CNA at 2.34. On the weekends, the total nursing staff was 3.25, RN and LPN at 1.2, and CNA 1.2.83 However, Comprehensive at Williamsville only met the CNA 2.2 HPRD and total staffing 3.5 HPRD minimum standard 63.33% and 66.67% of the time, respectively. While the facility did meet the LPN standard 84.44% of the quarter, as discussed below, Comprehensive at Williamsville relies heavily on LPNs and does not meet the recommended 0.4 HPRD for RNs as set forth in major CMS study.84
Comprehensiveat Williamsville reported lowHPRDforRNat 0.22,ranking 32nd outof35nursing homes in Erie County and well below the NYS average of 0.51. In addition, Comprehensive at Williamsville heavily relies on LPNs to provide nursing care, with LPNs accounting for 83.40% oftheRNandLPNNYS minimum1.1HPRDstandard.Comprehensiveranks2nd outof35nursing homes in Erie County in its reliance on LPNs over RNs. Numerous studies have demonstrated that higher RN staffing levels results in better outcomes including: increased functional improvement, reduced incontinence, reduced urinary tract infections and catheterizations, reductions in pain, pressure ulcers, weight loss and dehydration, use of antipsychotics, infections, falls, adverse outcomes, and mortality rates.85
82 For more information see https://www.cms.gov/medicare/quality-initiatives-patient-assessmentinstruments/nursinghomequalityinits/staffing-data-submission-pbj , and https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-45.pdf
83 See CMS PBJ data , accessed here
84 See Kramer AM, Fish R. “Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care.” Chapter 2 in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. Abt Associates, Inc., Winter 2001.
85 For example, see Horn SD, Sharkey SS, Hudak S, Smout RJ, Quinn CC, Yody B, Fleshner I. Beyond CMS quality measure adjustments: identifying key resident and nursing home facility factors associated with quality measures. J Am Med Dir Assoc. 2010 Sep;11(7):500-5. doi: 10.1016/j.jamda.2009.10.008. Epub 2010 Apr 3. PMID: 20816338.). For additional information, visit: https://theconsumervoice.org/issues/other-issues-andresources/staffing
Comprehensive at Williamsville also heavily relies on contracted nursing staff compared to other nursing homes in Erie County:
Rank (of 35 nursing homes)
Comprehensive at Williamsville % Contract
Erie County Average Erie County Median Erie County Range %
RN 3rd 35.02% 5.96% 0 0-62.37%86
LPN 3rd 76.16% 19.23% 11.14% 0-84.65%87 CNA 6th 44.40% 18.80% 12.97 0-64.39%88
The Care Compare Data further shows Comprehensive at Williamsville has high nurse turnover ratesand ranks 1st out of3289 nursinghomesforboth total nurseturnover(83.2%)andRNturnover (80%).90 The average total nurse turnover and RN turnover in Erie County is 57.79% and 58.79% respectively. The median: 58.45% and 50%. Higher nurse turnover is associated with poorer quality of care.91
When Comprehensive at Williamsville took over ownership/operations of the facility, the facility was rated 4-star for staffing in 2014 and 2015. 92 However in 2016, after what was likely implementation of the staffing cuts as stated in both CON ownership change documents, the facility dropped to a 1 star and is currently rated as a 2 star.93
Nurses have complained about staff pay and adequate compensation in the media. 1199SEIU United Healthcare Worker East is a union representing the staff at Comprehensive at Williamsville.94 Some staff like Tania Green, a nursing assistant at Comprehensive, complained about working holidays like Christmas and New Year but have not received all the holiday pay they were promised. Darlene Gates, a 1199SEIU organizer, is quoted as saying “When it comes to holiday pay in our contract, or any type of pay that our members are due, I’m forced to file grievances, go have meetings, andit may take morethan onemeetingjust to get people’s pay right.” Ephram Lahasky, however, was quoted as saying he was not aware of the union’s concerns
86 Safire Rehabilitation of Southtown has the highest: 62.37%
87 Ellicott Center for Rehabilitation and Nursing has the highest: 84.65% 88 Buffalo Center for Rehabilitation and Nursing has the highest: 64.39%
89 Note: 3 nursing homes (Rosa Coplon, Schofield, Terrace View are not included because they either did not submit staffing data, or submitted data that did not meet the criteria required to calculate a staffing measure. See NH Primary Data Dictionary, available at: https://data.cms.gov/provider-data/topics/nursing-homes
90 CMS Provider October 1, 2022
91 Zheng Q, Williams CS, Shulman ET, White AJ. Association between staff turnover and nursing home qualityevidence from payroll-based journal data. Journal of the American Geriatrics Society. May 2022. doi:10.1111/jgs.17843
92 CMS Provider- Archives 93 CMS Provider October 1, 2022
94 https://www.marketwatch.com/story/all-you-hear-about-is-the-bad-stuff-ephram-lahasky-has-a-new-investmentmodel-for-americas-nursing-homes-regulators-have-questions-11648041864
regarding inadequate compensation at his facilities 95 Investment in the people who provide the nursing and other services such as housekeeping, dietary and maintenance, is essential.
Care Compare also provides the following information comparing Comprehensive at Williamsville’s staffing to the NYS and National averages:96
Comprehensive at Williamsville NYS Federal
Total # Nurse Staff HPRD 3 hours 43 mins 3 hours 34 mins 3 hours 46 mins
RN HPRD 27 mins 42 mins 40 mins
LPN HPRD 1 hour 10 mins 47 mins 53 mins
CNA HPRD 2 hours 6 mins 2 hours 5 mins 2 hours 13 mins
Weekend: Total # Nurse Staff HPRD 3 hours 6 mins 3 hours 2 mins 3 hours 15 mins
Weekend: RN HPRD 13 mins 27 mins 27 mins Turnover: Total Nurse Staff 83.2% 45% 53.5%
Turnover: RN 80% 47.9% 52.3%
Quality Measures
Care Compare reports on numerous quality measures. Fifteen of these quality measures are included in the facility’s CMS Care Compare rating. The majority, ten, of the quality measures are based on facility reported data drawn from the Minimum Data Set (MDS); not claims based data. The MDS form is completed by the nursing home for every one of its residents and is a tool for standardized assessment and for facilitating care management.97 Only five quality measures from which the facility receives its quality measure rating are from Medicare claims-based data.
Comprehensive at Williamsville’s rating on quality measures is “below average” according to the CMS rating system (2 stars of 5) and is also rated 2 for both long-stay and short-stay measures.
The below table shows the quality measures reported by Comprehensive at Williamsville and how they compare with the NYS average for the most recent reporting periods.98 The following quality measure results cause rise for concern:
95 https://www.marketwatch.com/story/all-you-hear-about-is-the-bad-stuff-ephram-lahasky-has-a-new-investmentmodel-for-americas-nursing-homes-regulators-have-questions-11648041864
96 CMS Care Compare, accessed December 5, 2022 https://www.medicare.gov/care-compare/details/nursinghome/335172?id=d53deefa-ffc1-48a0-b1c412f2f00d5fb1&city=Williamsville&state=NY&zipcode=&measure=nursing-home-staffing
97 For additional details, see page 15 the Technical Users’ Guide for the CMS Five-Star Quality Rating System (October 2022) https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/Downloads/usersguide.pdf
98 The time period depends on the quality measure: https://data.cms.gov/provider-data/topics/nursing-homes/qualityof-resident-care#quality-measure-data-collection-periods . For additional information on Quality Measures and the
Use of antipsychotic and psychotropic medications99
• % of short-stay residents who got antipsychotic medication for the first time (lower % better): Comprehensive at Williamsville 4.8%, NYS: 19.1%, National: 19.1%
• % of long-stay residents who got an antipsychotic medication (lower % better): Comprehensive at Williamsville: 24.5%; NYS: 11.6%; National: 14.5%
• % of long-stay residents who got an antianxiety or hypnotic medication (lower % better): Comprehensive at Williamsville: 20.3%; NYS 13.3%, National: 19.5%
Comprehensive at Williamsville was cited on its most recent annual inspection, August 27, 2021, for failing to document targeted behaviors and ongoing behaviors to support the use of antipsychotic medication and lack of attempted gradual dose reduction as required by federal regulation. In addition, the resident lacked a comprehensive care plan for antipsychotic medication use.100
Quality of Care
• % of residents with pressure ulcers/pressure injuries that are new or worsened (lower % better): Comprehensive at Williamsville: 11.2%, National: 2.9%
• % of long-stay residents whose ability to move are independently worsened (lower % better): Comprehensive at Williamsville: 38.2%, NYS: 16.3%, National: 17.2%
• % of long-stay residents whose need for help with daily activities has increased (lower % better): Comprehensive at Williamsville: 27%; NYS: 14.9%; National: 14.7%
When reviewing the table, it is important to remember that the majority of the quality measures are self-reported by the facility through the MDS and are not claims based. For ease of identification, we have italicized the quality measures that are claims based and included in the Care Compare quality measure star rating, and CAPITALIZED the quality measures that are FACILITY REPORTED and included in the quality measure rating.
NHC star rating: Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide.” Updated October 2022.
99 For information on why the use of these medications are of concern see: https://oig.hhs.gov/oei/reports/OEI-0719-00490.asp; https://nursinghome411.org/issue-alert-antipsychotic-drugs/ https://theconsumervoice.org/issues/issue_details/misusing-antipsychotics ; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7110922/ ; and https://www.hrw.org/news/2022/09/19/chemicalrestraints-deprive-older-people-liberty .
100 August 27, 2021 annual inspection, Event ID: I20111
Short Stay Quality Measures
Worse than State Average for Short-Stay Residents
Comprehensive at Williamsville NYS Average Ratio
% of short-stay residents who were rehospitalized after a nursing home admission (lower % better)
% of short-stay residents who have had an outpatient emergency department visit (lower % better)
% OF SHORT-STAY RESIDENTS WHO GOT ANTIPSYCHOTIC MEDICATION FOR THE FIRST TIME (LOWER % BETTER)
% OF RESIDENTS WITH PRESSURE ULCERS/PRESSURE INJURIES THAT ARE NEW OR WORSENED (LOWER % BETTER)
% of residents who are at or above an expected ability to care for themselves at discharge (higher % better)
% of residents who are at or above an expected ability to move around at discharge (higher % are better)
21.4% 19.1% 1.12
12.6% 8.8% 1.43
4.8% 1.5% 3.2
11.2% 2.9% (national) 3.86
39.1% 46.9% (national) 0.83
39.1% 40.1% 0.98
Rate of successful return to home or community from a SNF (higher rates better) 40.2% 52.7% 0.76
Better than State Average for Short-Stay Residents
% OF SHORT-STAY RESIDENTS WHO IMPROVED IN THEIR ABILITY TO MOVE AROUND ON THEIR OWN (HIGHER % BETTER)
% of short-stay residents who needed and got a flu shot for the current flu season (higher % better)
% of short-stay residents who needed and got a vaccine to prevent pneumonia (Higher % better)
Comprehensive at Williamsville NYS Average Ratio
79.2% 75.3% 1.05
77.5% 74.9% 1.03
86% 71.1% 1.21
% of residents whose medications were reviewed and who received follow-up care 100% 91.1% (national) 1.10
when medication issues were identified (higher % better)
% of SNF residents who experience one or more falls with major injury during their SNF stay
% of SNF residents whose functional abilities were assessed and functional goals were included in their treatment plan (higher % better)
0% 1% (national)
100% 98.8% 1.01
Change in residents’ ability to care for themselves (higher scores are better) 7.6 7.2 (national) 1.06
Change in residents’ ability to move around (higher scores are better) 17.1 16.5 (national) 1.04
% of SNF healthcare personnel who completed COVID-19 primary vaccination series (higher scores are better)
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (lower rates better)
% of infections patients got during their snf stay that resulted in hospitalization (lower rates better)
93.8% 77.5% (national) 1.21
7.5% 7.8% (national
6.3% 7.5% (national)
Medicare Spending Per Beneficiary for residents in snfs (displayed as a ratio) 0.80 National Average 1.03
Long-Stay Quality Measures
Worse than State Average for Long-Stay Residents
Comprehensive at Williamsville NYS Average Ratio
Number of outpatient emergency department visits per 1,000 long-stay resident days (lower numbers better)
0.93 0.69 1.35
% of long-stay residents who got an antipsychotic medication (lower % better) 24.5% 11.6% 2.11
% OF LONG-STAY RESIDENTS WHO HAVE OR HAD A CATHETER INSERTED AND LEFT IN THEIR BLADDER (LOWER % BETTER)
% OF LONG-STAY RESIDENTS WHOSE ABILITY TO MOVE ARE INDEPENDENTLY WORSENED (LOWER % BETTER)
2.7% 2.1% 1.29
38.2% 16.3% 2.34
% OF LONG-STAY RESIDENTS WHOSE NEED FOR HELP WITH DAILY ACTIVITIES HAS INCREASED (LOWER % BETTER)
% of long-stay residents who needed and got a flu shot for the current flu season (higher % better)
% of long-stay residents who got an antianxiety or hypnotic medication (lower % better)
27% 14.9% 1.81
82.8% 95.5% 0.87
20.3% 13.3% 1.53%
Better than State Average for Long-Stay Residents Comprehensive at Williamsville
NYS Average Ratio
Number of hospitalizations per 1,000 longstay resident days (lower numbers better) 0.99 1.31 0.76
% OF LONG-STAY RESIDENTS EXPERIENCING ONE OR MORE FALLS WITH MAJOR INJURY (LOWER % BETTER)
% LONG-STAY HIGH-RISK RESIDENTS WITH PRESSURE ULCERS (LOWER % BETTER)
% OF LONG-STAY RESIDENTS WITH A URINARY TRACT INFECTION (LOWER % BETTER)
% of long-stay residents who needed and got a vaccine to prevent pneumonia (higher % better)
2.1% 3% 0.7
9% 9.5% 0.95
0% 2.1%
92.2% 89.6% 1.03
% of long-stay residents who were physically restrained (lower % better) 0% 0.2%
% of long-stay low-risk residents who lose control of their bowels or bladder (lower % better)
43% 54% 0.80
% of long-stay residents who lose too much weight (lower % better) 4.4% 6.3% 0.70
% of long-stay residents who have symptoms of depression (lower % better) 0.4% 13% 0.03
New York Department of Health Nursing Home Quality Initiative
The NYS DOH Nursing Home Quality Initiative (NHQI) is an annual quality and performance evaluation project to improve the quality of care for residents in NYS Medicaid-certified nursing homes. The NHQI offers an alternative method of ranking nursing homes to CMS Nursing Home Compare. The 2020 NHQI is based on the previous calendar year’s performance in 3 component areas: Quality (quality measures); Compliance (compliance with reporting); and Efficiency (potentially avoidable hospitalizations) categories. The overall score is worth a maximum of 90 points (this is a reduction from the previous NHQI max score of 100 due to a removal of employee flu vaccination measures).101
NHQI: Quality Component (worth 65 points)
These are measured from MDS 3.0 data, CMS Payroll Based Journal PublicUse Files (PBJ PUFs), and Nursing Home Compare data. The points are evenly distributed for all quality measure and include 13 quality measures each worth a maximum of 5 points.
NHQI: Compliance Component (worth 15 points)
These consist of two measures: CMS five-star quality rating for health inspections and timely submission ofnursing homecertifiedcost reports. Healthinspectionsurvey scores aredownloaded directly from CMS and are scored as follows: 10 points=5 stars, 7 points=4 stars, 4 points=3 stars, 2 points=2 stars, and 0 points=1 star. Timely submission measures are specified by the Bureau of Residential Health Care Reimbursement and are worth a maximum of 5 points13 .
NHQI: Efficiency Component (worth 10 points)
This consists of one measure: potentially avoidable hospitalizations. The rate is calculated for each quarter and the averaged to create an annual average in order to stay consistent with other CMS quality measures. The measure is risk-adjusted. Scores are given as follows: Quintile 1=10 points, Quintile 2=8 points, Quintile 3=6 points, Quintile 4=2 points, and Quintile 5=0 points13 .
Any facility that was cited for a letter J, K, or L health inspection deficiency one or more times are not eligible to be ranked into overall quintiles. This is because these letter deficiencies indicate Level 4 immediate jeopardywhichis the highest level ofseverity forhealthinspectiondeficiencies
The total scores are grouped into five quintiles (or tiers). Facilities in the first quintile are the top performing NY nursing homes. Comprehensive at Williamsville has been ranked in the worse quintile (5) in every year of the NHQI’s existence. 101https://www.health.ny.gov/health_care/medicaid/redesign/nhqi/2020/methodology.htm
2016-5th quintile 2017- 5th quintile 2018- 5th quintile 2019- 5th quintile 2020- 5th quintile
Federal and State Enforcement
Nursing homes in NYS must follow Federal and NYS laws in order to remain in operation (or at least receive Medicare and/or Medicaid payments). Federal enforcement actions (“remedies”) are imposed by CMS when the state survey agency (DOH for NYS) determines there are violations of nursing home law and regulations.102 The worse thing that may happen, is CMS terminates the Medicare/Medicaid contract with the facility. This is rare. CMS may also impose a fine (referred to as civil monetary penalty) or deny payment for new Medicare/Medicaid resident admissions.
Comprehensive at Williamsville was issued a federal fine of $9,750 on August 27, 2021, due to the serious health issues identified upon inspection.
At the state level, the DOH imposes fines for violations of NYS law and regulations. Fines were seen to be increasing in many WNY nursing homes during the COVID-19 pandemic for safety violations.103 Comprehensive at Williamsville has agreed to pay for fines to the NYSDOH on 3 separate occasions for violations of COVID-19 safety regulations:
- July 9, 2021 Stipulation and Order NH-21-134104
o Comprehensive to pay $2,000 for regulatory violation 10 NYCRR §415.19(f)(1) Quality of Care. DOH ordered this from its review of COVID19 NH Daily data for NHs (nursing homes) report and found that Comprehensive failed to maintain the required supply of all necessary items of PPE required.
- April 1, 2021 Stipulation and Order NH-21-062105
o Comprehensive to pay $12,000 for regulatory violation 10 NYCRR §415.19(a)(1) Infection Control and Quality of Care. On October 7, 2020, the DOH cited numerous deficiencies for violations under infection control for a failure to check all staff for COVID-19 symptoms at the start of each shift and every 12 hours on duty.
102 See 42 CFR 488.406, and State Operations Manual, Chapter 7 for additional information.
103 Specht, Charlie, “WNY nursing homes were fined $214,000 for COVDI-19 deficiencies”, WKBW (Jan. 29, 2021) https://www.wkbw.com/news/i-team/wny-nursing-homes-were-fined-214-000-for-covid-19-deficiencies 104 https://profiles.health.ny.gov/nursing_home/stip_detail/pfi274nh_21_134.pdf 105 https://profiles.health.ny.gov/nursing_home/stip_detail/pfi274nh_21_062.pdf
- July 8, 2020 Stipulation and Order NH-20-027106
o Comprehensiveto pay$14,000forregulatory violations 10NYCRR §415.19(a)(1), 10 NYCRR §415.19(a)(2), and 10 NYCRR §415.19(b)(1) Infection Control, social distancing and hand hygiene. On May 20, 2020, the DOH cited numerous deficiencies for violations under infection control: failure to practice social distancing on 2 of 4 units, failure to assess residents for COVID-19 symptoms, failure to ensure staff wore gloves when entering resident rooms and completing hand hygiene upon leaving resident rooms.
Comprehensive at Williamsville also agreed to pay fines prior to the pandemic. The largest fines agreed to were during the months of February and June 2016, where Comprehensive at Williamsville paid $20,000 and $21,000 respectively for multiple deficiencies:
- March 27, 2019 Stipulation and Order NH-19-016107
o Comprehensive at Williamsville to pay $6,000 for regulatory violations identified by the DOH on October 16, 2018, June 8, 2017, and June 8, 2015.
- December 12, 2017 Stipulation and Order NH-17-063108
o Comprehensive at Williamsville to pay $8,000 for regulatory violations identified by the DOH on June 8, 2016, June 8, 2017, and August 20, 2015.
- December 6, 2016 Stipulation and Order NH-16-208109
o Comprehensiveto pay$21,000forregulatory violations 10NYCRR §415.12(c)(2), §415.4(b)(1)(ii)(a,b), §415.26, §415.27(c)(3)(v), and §415.4(b). DOH cited the deficiencies on June 8, 2016 where it determined Comprehensive at Williamsville violated many codes including quality of care- pressure sores, investigate report, administration, quality assurance, and develop abuse neglect policies.
- June 28, 2016 Stipulation and Order NH-16-177110
o Comprehensive at Williamsville to pay $20,000 for regulatory violation 10 NYCRR §415.12 Quality of Care-highest practicable care and enteral feeding tubes. DOH cited the deficiencies on February 29, 2016
106
https://profiles.health.ny.gov/nursing_home/stip_detail/pfi274nh_20_027.pdf 107
https://profiles.health.ny.gov/nursing_home/stip_detail/pfi274nh_19_016.pdf 108
https://profiles.health.ny.gov/nursing_home/stip_detail/pfi274nh_17_063.pdf 109
https://profiles.health.ny.gov/nursing_home/stip_detail/pfi274nh_16_208.pdf 110
https://profiles.health.ny.gov/nursing_home/stip_detail/pfi274nh_16_177.pdf
Summary: The Need to Improve Quality of Care and Quality of Life
While there are nursing homes in WNY that do provide quality and safe care, too many do not. As stand-alone facilities sell to for-profit, multi-facility ownership entities, there must be greater oversight and enforcement to ensure they provide safe and quality care to all residents.
In operating a nursing home, owners make a promise to the residents, the community (taxpayer) and the government that they will provide safe and quality care in return for Medicare and Medicaid payments. It is a legal and moral obligation to provide such. However too often staff are cut, and other measures are taken that impede resident safety to the benefit of the ownership group. In Comprehensive at Williamsville’s case, it is clear the ownership sought, and has acted, to save money through cuts in staffing (both numbers and benefits). Whether the ownership is siphoning funds away from the facility, as has been alleged in AG James’ lawsuit against the Villages of Orleans, and in Sam Halper’s federal case, is definitely a question worth investigating. In addition, the publicly available information detailed above shows similarities to that detailed in AG James’ lawsuit against the Villages of Orleans.
Red flags should have been raised at the NYS level pretty immediately upon Comprehensive Healthcare Management Services, LLC’s takeover of St. Francis and this operator group’s ability to own/operate other nursing homes in NYS. For example:
• Health deficiency weighted score after revisits for the August 20, 2015 survey cycle period totaled 270 points. This is approximately 4x the points when officially owned by Catholic Health System for the December 18, 2014 survey cycle, and 13.5x higher than the December 10, 2013 survey cycle.
o 2013 while owned by Catholic Health System: 8 federal deficiencies, one cited at “E” scope/severity (no actual harm with the potential for more than minimal harm that is not immediate jeopardy but is a pattern).
o 2014: while owned by Catholic Health System: 15 federal deficiencies, 2 cited at “E” scope/severity.
o 2015: 30 federal deficiencies, 16 cited at “E scope/severity; >53% of the deficiencies.
• Health deficiency weighted score after revisits for the June 8, 2016 survey cycle period totaled 428 points. This is approximately 1.6x the points from the August 20, 2015 period.
o 2016: 33 federal deficiencies, 1 cited at “G” scope/severity (Actual Harm that is not immediate Jeopardy), 5 cited at “F” scope/severity (No actual harm with potential for more than minimal harm that is not immediate jeopardy that is widespread)), 7 cited at “E” scope/severity. 18.2% of the deficiencies were for substandard quality of care.
• The CMS star rating for staffing drastically fell from 4 stars in 2014 and 2015 to 1 star in 2016.
• Aftertakingoverthetwo adult homes: Symphony Livingat Dunkirkclosed onJanuary7, 2018, and Symphony Living atLancaster’s caredrastically declined, andoperations wereturned over November 15, 2017.
While Comprehensive at Williamsville during the current 3 cycle survey period has not been cited at Actual Harm and does not have the distinction of having the worse survey points in Erie County, 111 issues with resident care and safety remain. Comprehensive at Williamsville continually fails to rectify violations of federal and state nursing home resident rights and care regulations, is one of the highest utilizers of contract staff in Erie County, relies heavily on LPNs instead of RN, and has the highest nurse turnover rates in Erie County. In addition, the physical environment of Comprehensive at Williamsville has declined since current ownership’s takeover of operations and the facility.
During the course of the COVID-19 pandemic, there were many legislative changes and additions to the NYS Public Health law to address issues of substandard care in nursing homes. These included: minimum nurse staffing standards, nursing home disclosure requirements, and updates to the ownership change certificate of needs requirements. While these new laws are not perfect, they must be fully enforced and not eroded by the nursing home industry and its lobby. In addition, the DOH and others must scrutinize operator cost reports and related party transactions.
When a for profit operator purchases and/or takes over operations of a nursing home, the operator makes a legal promise to abide by the federal and state standards. There must be accountability.
111 That distinction goes to Buffalo Center for Rehabilitation and Nursing, with 184.33 total points for the current Cycle 1 period.