Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harris Hill Nursing Facility, L L C during CMS and state inspections, most recent first.
Staff failed to maintain a resident’s dignity when two resident assistants were in the resident’s room using personal cell phones while the resident was yelling for assistance. The resident had cognitive impairment, HF, and COPD, and was supposed to receive 1:1 visits and support. Both aides acknowledged they should not have been on their phones in front of the resident, and the LPN, SW, DON, and Administrator all stated staff should have been engaging with the resident instead of using personal devices.
A resident with stroke, hemiplegia, and dementia did not have the wheelchair foot buddy applied as directed in the care plan and Kardex. Staff observed the resident in the wheelchair without the device while the legs moved behind the foot pedals, and a CNA stated they forgot to apply it. An LPN confirmed the device was missing, and the DON and DOR stated the foot buddy remained appropriate and should have been used as planned.
A resident with CHF had ordered daily weights missed on multiple days, including instances where weight gains exceeded ordered parameters without provider notification. Another resident with dementia had a left elbow bruise that was not identified or documented during the weekly skin inspection. A cognitively intact resident had Tylenol left at bedside for self-administration without an active MD order authorizing it, despite staff confirming that such an order was required.
Meal tickets were not followed for several residents. A resident with DM, schizophrenia, and dysphagia did not receive the pancakes or juice listed on the meal ticket during observations, while two other residents with stroke-related deficits and dementia were not served the foods, fluids, or adaptive equipment documented for them. Staff and the RD stated residents should receive or at least be offered the items on their meal tickets, but the observed meals did not match the documented orders and preferences.
Unlabeled, expired, and personal food items were found in Unit A and Unit D servery refrigerators, along with soiled refrigerator surfaces and food debris on the floor. Staff interviews confirmed that opened items should be dated, discarded within the required time frame, and kept separate from personal items, and that the servery areas should be clean and sanitary.
A resident with multiple diagnoses, including glaucoma, was observed self-administering eye drops without an assessment or physician's order, contrary to facility policy. The comprehensive care plan required nursing staff to administer the medication, but the resident stored and used the medications independently. Staff interviews confirmed the lack of an assessment tool, physician's order, and documentation, leading to a deficiency.
A resident with hemiplegia was injured during a transfer when a CNA failed to follow the care plan requiring two-person assistance, resulting in a leg injury. The CNA attempted the transfer alone, leading to a hematoma. Staff interviews confirmed the neglect due to non-adherence to the care plan.
A resident received long-term prophylactic antibiotics without proper monitoring by the facility's Antibiotic Stewardship Program. Despite recommendations for regular lab tests and follow-up appointments, these were not completed or communicated to the infectious disease provider. Interviews revealed a lack of coordination among staff, including the LPN, Unit Manager, and DON/Infection Preventionist, leading to a deficiency in the facility's infection prevention and control program.
Staff Used Personal Cell Phones While Resident Called for Help
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when two resident assistants were in the resident’s room using their personal cell phones while the resident was calling out for assistance. The resident was sitting in a wheelchair in the room yelling for help, while one resident assistant stood about three feet away facing the window and tapping on a phone screen, and the other sat in a recliner behind the resident with a lit phone screen. The resident assistants stated they were assigned to keep the resident company and busy to help lower anxiety, but both were using their phones instead of engaging with the resident. The resident involved had diagnoses including cognitive communication deficit, heart failure, and COPD. The MDS documented moderate cognitive impairment, with the resident able to understand and be understood by others. The care plan identified a potential for alteration in psychosocial well-being and mood related to medical condition, adjustment to subacute rehabilitation, and confusion at times, with interventions to respect and listen to expression of feelings and establish trust. The Kardex indicated the resident required minimal assistance of one staff member for ADLs and was to receive 1:1 visits and transportation to activities as desired. During interviews, one resident assistant stated they were on a personal call from a family member and acknowledged that being on a phone in front of a resident was disrespectful. The other resident assistant stated they were shutting off a phone alarm and also acknowledged that staff should not be on their phones in front of residents because it was disrespectful and distracting. The LPN stated both resident assistants should have been engaging with the resident and neither should have been using personal phones. The SW, DON, and Administrator all stated staff should not use personal cell phones in resident care areas and should have been giving attention to the resident.
Failure to Apply Wheelchair Foot Buddy as Care Planned
Penalty
Summary
Resident #119 did not receive the foot buddy that was documented in the comprehensive care plan and Kardex for wheelchair positioning. The resident had diagnoses including stroke with hemiplegia and dementia, and the MDS documented moderate cognitive impairment. The care plan dated 01/28/2026 identified self-performance deficits related to activity intolerance, limited mobility, and limited range of motion, and included the intervention to use a foot buddy when out of bed in a wheelchair. The Kardex dated 04/20/2026 also directed staff to apply the foot buddy when the resident was in the wheelchair. Observations showed the resident in the dining room and in front of the community television in the wheelchair without the foot buddy in place, with both legs moving behind the wheelchair foot pedals. A foot buddy was observed on the floor next to the resident's nightstand in the room. CNA #3 stated they were responsible for the resident's care on 04/14/2026 and 04/17/2026 and said they must have forgotten to apply the foot buddy. LPN #4 also observed the resident without the foot buddy in place and confirmed the resident was supposed to use it to keep the legs from falling through the wheelchair pedals. The Director of Therapy stated the foot buddy remained appropriate and expected staff to follow the plan of care, and the DON stated staff should have applied it as recommended by therapy.
Failure to Follow Orders for Weights, Skin Checks, and Bedside Medication Use
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with physician orders and the comprehensive care plan for three residents. One resident with congestive heart failure, COPD, respiratory failure, and a history of pulmonary edema was ordered daily weights because of fluid retention concerns, but weights were not obtained on multiple days in February, March, and April, and there was no documentation that the provider was notified when weight gains exceeded ordered parameters. Staff interviews confirmed that the resident was expected to be weighed daily, that missed weights occurred, and that the provider was not notified as required. A second resident with dementia, protein-calorie malnutrition, and reduced mobility had a weekly skin inspection order tied to shower care. During observation, the resident was found with an approximately three-inch multicolored bruise over the left elbow. The bruise was not documented on the skin inspection record, which had been signed as completed, and staff interviews showed that the bruise was not identified during the shower-day skin check or during routine hands-on care. The resident’s emergency contact was also unaware of any recent injury. A third resident who was cognitively intact and independent for decision-making had a care plan that allowed self-administration of medications as ordered and stored at bedside. Staff found Tylenol at the bedside, but there was no active physician order authorizing self-administration of that medication. Interviews with the DON and Administrator confirmed that a physician order was needed for bedside self-administration and that no such order was in place at the time the medication was left at the bedside.
Meal tickets, fluids, and adaptive equipment not followed
Penalty
Summary
The facility failed to ensure that menus and meal tickets were followed for residents in one dining room, resulting in residents not receiving all foods, fluids, and adaptive equipment listed for them. The report states that dietary personnel were expected to assemble trays according to the menu and special requests, nursing personnel were responsible for providing beverages and reviewing the menu with residents, and designated personnel were to visually check each tray for accuracy. The facility also had policies stating residents should receive sufficient fluids to maintain hydration and that residents requiring adaptive equipment should be issued the appropriate equipment at mealtimes. Resident #17 had diagnoses including type 2 diabetes mellitus, schizophrenia, and dysphagia, and was assessed as severely cognitively impaired and requiring supervision with eating. The resident’s care plan identified risks for altered nutrition and dehydration and included interventions for preferred fluids and meal plan adjustments. During one breakfast observation, the meal ticket listed two pancakes and two sausages, but the resident was served scrambled eggs, sausage, and toast. The resident stated they would have liked pancakes, and after staff were notified, two pancakes were provided and one was eaten. During another breakfast observation, the meal ticket listed coffee, juice, and milk, but the resident was only given milk and stated they would have liked juice, which was not provided. Resident #52 had diagnoses including stroke with hemiplegia, aphasia, and dementia, and was documented as severely cognitively impaired and requiring supervision with eating. The care plan identified a self-performance deficit for eating and documented the need for an inner lip plate, along with interventions for nutrition and hydration. During observations, the resident’s meal tickets listed pastries, banana, and multiple beverages including water, prune juice, house juice, and a mighty shake, but the resident was served different foods and only received chocolate milk or juice, with no other listed beverages provided. On another breakfast observation, the resident’s meal ticket again listed pastries and banana with an inner lip plate, but the resident was served eggs, toast, and oatmeal on a regular plate. Resident #119 had diagnoses including type 2 diabetes mellitus, stroke with hemiplegia, and dementia, and was documented as moderately cognitively impaired and requiring supervision with eating. The care plan identified risks for altered nutrition and dehydration. During lunch and breakfast observations, the meal tickets listed multiple beverages, including prune juice, milk, coffee, and house juice, but the resident received only one cup of juice and no additional fluids. Staff interviews confirmed that residents should be offered the items on their meal tickets and that the meal tickets should be followed unless the resident stated otherwise.
Unlabeled and Expired Food Stored in Servery Refrigerators
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in two unit serveries, Unit A and Unit D. Surveyors observed that both servery refrigerators contained unlabeled or out-of-date food and drink items, and that personal food was stored with residents’ food. The cited policy required opened items to be labeled and dated and discarded after three days, and non-potentially hazardous or time/temperature control for safety foods to be labeled and dated and discarded after five days once opened. In Unit D, the refrigerator handle was sticky with an unknown substance and the front of the refrigerator had streaks of food debris. Inside the refrigerator were multiple items including sliced cold cut bologna, ham, turkey, and cheese with dates ranging from 04/07/2026 to 04/09/2026, along with undated egg salad, undated sliced tomatoes, and two undated 64-ounce pitchers of juice. In Unit A, the servery floor had food debris, crumbs, dried spills, and a black substance buildup in front of the refrigerator. The refrigerator contained an unopened, unlabeled personal iced tea, opened and undated margarine, opened milk containers without dates, undated cups of juice and chocolate milk, undated bagels, raisin bread, English muffins, and frozen water bottles and an opened, unlabeled ginger-ale can in the freezer. During interviews, dietary staff stated that opened items should be dated and checked for expiration, that personal items should not be stored in the servery refrigerator, and that the floors should be swept and mopped regularly. Dietary staff and supervisory staff acknowledged that items should be dated and discarded within the required time frame, and that the servery areas should be kept clean and sanitary. The FSD, DON, and Administrator also stated that food and drinks should be labeled and dated and that a clean environment was expected.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed by the interdisciplinary team to determine their ability to safely self-administer medications. Resident #12, who has diagnoses including peripheral neuropathy, intraspinal abscess, and glaucoma, was observed with medications in their room and self-administered these medications without an evaluation. The facility's policy requires an assessment and a physician's order for self-administration, which was not completed for Resident #12. The resident's comprehensive care plan indicated that nursing staff should administer ophthalmic medication, yet the resident was storing and self-administering eye drops without documented approval. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that there was no assessment tool completed, no physician's order for self-administration, and no documentation in the comprehensive care plan. The facility's failure to follow its policy and procedure for self-administration of medications led to this deficiency.
Neglect Due to Non-Adherence to Care Plan During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by an incident involving a Certified Nurse Aide (CNA) who did not adhere to the care plan for a resident requiring assistance during transfers. The resident, who had a history of stroke and hemiplegia, was dependent on others for transfers and required the assistance of two staff members using a sit-to-stand lift. Despite this requirement, the CNA attempted to transfer the resident alone, resulting in an injury to the resident's left lower leg. The incident was documented in a nursing progress note and an incident report, which detailed that the resident's leg was injured during the transfer when it hit the bed rail. The resident experienced pain and swelling, leading to a hematoma, as confirmed by a radiology report. Interviews with the resident and staff members, including the CNA involved, confirmed that the care plan was not followed, and the CNA acknowledged the mistake, citing a lack of available assistance at the time. Interviews with other staff members, including a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the Administrator, reinforced the expectation that care plans should be followed to prevent neglect. The LPN and DON both stated that failing to adhere to the care plan constituted neglect, as it resulted in harm to the resident. The Administrator also emphasized the importance of following care plans to ensure resident safety.
Failure to Monitor Antibiotic Use for Resident
Penalty
Summary
The facility failed to ensure that its infection prevention and control program included antibiotic use protocols and a system to monitor antibiotic use for a resident. Specifically, a resident received prophylactic antibiotics, Rifampin and Bactrim, since October 2022 without ongoing monitoring by the Antibiotic Stewardship Program. The resident's comprehensive care plan did not include infectious disease consults and recommendations, and there was no documented evidence of laboratory tests or follow-up appointments with the Infectious Disease Physician. The resident was admitted with diagnoses including peripheral neuropathy, intraspinal abscess, and glaucoma. The resident was cognitively intact and had a risk for infection related to long-term prophylactic antibiotic use. Despite recommendations from the Infectious Disease Physician for regular blood work and follow-up appointments, these were not completed or communicated to the infectious disease provider. The facility's infection and antibiotic tracking tool lacked documentation of lab monitoring or communication with the infectious disease provider. Interviews with facility staff revealed a lack of communication and responsibility for ensuring the completion of recommended labs and appointments. The Licensed Practical Nurse, Unit Manager, and Director of Nursing/Infection Preventionist were not effectively coordinating to monitor the resident's antibiotic use. The Pharmacy Consultant and Medical Director were also unaware of the specific recommendations for the resident, indicating a breakdown in the facility's antibiotic stewardship program.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Williamsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canterbury Woods | 3.3 mi | ★★★★★ | 0 | 0 |
| Comprehensive Rehabilitation And Nursing Center At | 3.3 mi | ★★★★★ | 8 | 0 |
| Williamsville Suburban, L L C | 3.4 mi | ★★★★★ | 9 | 0 |
| Elderwood At Williamsville | 3.6 mi | ★★★★★ | 1 | 0 |
| Elderwood At Lancaster | 4.4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.