Summary of Staffing Data for Comprehensive at Williamsville

Comprehensive at Williamsville is also cited at higher numbers compared to the NYS and National 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

Comprehensive at Williamsville reported low HPRD for RN at 0.22, ranking 32nd out of 35 nursing 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% of the RN and LPN NYS minimum 1.1 HPRD standard. Comprehensive ranks 2nd out of 35 nursing 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 LPN 3rd CNA 6th 35.02% 5.96% 0 0-62.37%86 76.16% 19.23% 11.14% 0-84.65%87 44.40% 18.80% 12.97 0-64.39%88

The Care Compare Data further shows Comprehensive at Williamsville has high nurse turnover rates and ranks 1st out of 3289 nursing homes for both total nurse turnover (83.2%) and RN turnover (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, and it may take more than one meeting just 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 quality evidence 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