Brothers of Mercy Nursing & Rehabilitation Center

Brothers of Mercy Nursing & Rehabilitation Center

10570 Bergtold Road

Clarence, NY 14031

(716) 759-6985

brothersofmercy.org/

Services: Baseline Services

Beds

Behavioral Intervention:
Pediatric:
Pediatric Ventilator Dependent:
Residential Health Care:240
Transitional Care Unit:
Ventilator Dependent:
Total Number of Beds:240

Administrative

Ownership: Voluntary--Not for Profit Corporation

Operated by: Brothers of Mercy Nursing Home Company Inc
4520 Ransom Road
Clarence, NY 14031

Permanent Facility Identifier: 296

Operating Certificate: 1456300N

Medicaid Certified

Medicare Certified

Medicare Number: 335112

Statistics

Employee Flu Vaccination Rate: 70%

Occupancy Rate: 90%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain12.065633/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened0.260983/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine94.766963/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine96.498723/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication2.367683/1/2017
471Percentage of short-stay residents who made improvements in function44.84993/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased14.060033003/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain3.949341003/1/2017
403Percentage of high risk long-stay residents with pressure ulcers4.031008003/1/2017
404Percentage of long-stay residents who lose too much weight2.745665003/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder56.504067003/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder1.671508003/1/2017
407Percentage of long-stay residents with a urinary tract infection0.970876003/1/2017
408Percentage of long-stay residents who have depressive symptoms3.511237003/1/2017
409Percentage of long-stay residents who were physically restrained0.000000003/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury0.692523003/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine99.193549003/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine99.168974003/1/2017
419Percentage of long-stay residents who received an antipsychotic medication9.691011003/1/2017
451Percentage of long-stay residents whose ability to move independently worsened32.858238003/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication16.091955003/1/2017

Complaints

Number of Standard Health Deficiencies:14
Number of Live Safety Code Deficiencies:10
Number of Total Deficiencies:24
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:0
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :0
Total intakes received (last three years):46
Intakes received per 100 occupied beds (last three years):21.1
Percent of total intakes received that were facility self reported incidents (last three years):85
On-site complaint investigations (last three years):13
Complaint investigations resulting in citations (last three years):1
Complaint investigations resulting in citations per 100 occupied beds (last three years):0.5
Complaint Citations in deficiency category: Administration:0
Complaint Citations in deficiency category: Quality of Care:0
Complaint Citations in deficiency category: Resident Rights:1
Complaint Citations in deficiency category: Dietary Services:0
Complaint Citations in deficiency category: Physical Environment:0
Complaint Citations in deficiency category: Other Services:0
Complaint Citations across all deficiency categories (last three years):1

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
11/13/2013Certification2
11/24/2014Certification2
12/23/2015Certification2
2/7/2017Certification1

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate citation corrected
LSC22
LSC22
LSC22
HealthFACILITY IS FREE OF ACCIDENT HAZARDS22
HealthRIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES21
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS11
LSCDOORS IN FIRE AND SMOKE PARTITIONS221/1/2014
LSCSPRINKLER SYSTEM MAINTENANCE231/1/2014
HealthDIGNITY211/20/2015
HealthCOMPREHENSIVE ASSESSMENTS211/20/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS211/20/2015
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS221/20/2015
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS221/20/2015
LSCSPRINKLER SYSTEM MAINTENANCE221/23/2015
HealthDIGNITY211/8/2014
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN211/8/2014
HealthFACILITY IS FREE OF ACCIDENT HAZARDS211/8/2014
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS212/15/2016
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES222/15/2016
HealthFACILITY PROVIDES SPECIALIZED REHABILITATION SERVICES212/15/2016
LSCAUTOMATIC SPRINKLER SYSTEM222/15/2016
LSCSPRINKLER SYSTEM MAINTENANCE222/15/2016
LSCPIPED-IN OXYGEN SYSTEM222/15/2016
LSCEMERGENCY PLAN222/15/2016
HealthHOUSEKEEPING AND MAINTENANCE SERVICES212/15/2016