Brothers of Mercy Nursing & Rehabilitation Center

Brothers of Mercy Nursing & Rehabilitation Center

10570 Bergtold Road

Clarence, NY 14031

7167596985

brothersofmercy.org/

Services: Baseline Services, Outpatient/Occupational Therapy, Outpatient/Physical Therapy, Outpatient/Speech Language Pathology Therapy

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: 88%

Occupancy Rate: 95%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine98.280011/1/2019
434Percentage of short-stay residents who newly received an antipsychotic medication1.480011/1/2019
471Percentage of short-stay residents who made improvements in function46.770011/1/2019

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased17.800011/1/2019
404Percentage of long-stay residents who lose too much weight4.440011/1/2019
405Percentage of low risk long-stay residents who lose control of their bowels or bladder59.270011/1/2019
406Percentage of long-stay residents with a catheter inserted and left in their bladder1.440011/1/2019
407Percentage of long-stay residents with a urinary tract infection1.430011/1/2019
408Percentage of long-stay residents who have depressive symptoms4.350011/1/2019
409Percentage of long-stay residents who were physically restrained0.000011/1/2019
410Percentage of long-stay residents experiencing one or more falls with major injury1.290011/1/2019
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine99.710011/1/2019
419Percentage of long-stay residents who received an antipsychotic medication7.340011/1/2019
451Percentage of long-stay residents whose ability to move independently worsened24.160011/1/2019
452Percentage of long-stay residents who received an antianxiety or hypnotic medication12.920011/1/2019

Complaints

Number of Standard Health Deficiencies:8
Number of Live Safety Code Deficiencies:11
Number of Total Deficiencies:19
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):49
Intakes received per 100 occupied beds (last three years):22.2
Percent of total intakes received that were facility self reported incidents (last three years):88
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
12/23/2015CERTIFICATION2
2/7/2017CERTIFICATION/COMPLAINT2
6/5/2018CERTIFICATION/COMPLAINT2
7/15/2019CERTIFICATION2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS217/15/20192/15/2016
HealthHOUSEKEEPING & MAINTENANCE SERVICES217/15/20192/15/2016
HealthPROVIDE/OBTAIN SPECIALIZED REHAB SERVICES217/15/20192/15/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES227/15/20192/15/2016
LSCLIFE SAFETY CODE STANDARD227/15/20192/15/2016
LSCLIFE SAFETY CODE STANDARD227/15/20192/15/2016
LSCLIFE SAFETY CODE STANDARD227/15/20192/15/2016
LSCLIFE SAFETY CODE STANDARD227/15/20192/15/2016
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE227/15/20193/27/2017
LSCHAZARDOUS AREAS - ENCLOSURE227/15/20193/27/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES227/15/20194/3/2017
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES217/15/20194/3/2017
LSCEGRESS DOORS227/15/20194/7/2017
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER217/15/20198/1/2018
HealthTUBE FEEDING MGMT/RESTORE EATING SKILLS217/15/20199/9/2019
LSCDOORS WITH SELF-CLOSING DEVICES217/15/20199/9/2019
LSCELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS227/15/20199/9/2019
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE217/15/20199/9/2019
LSCGAS EQUIPMENT - CYLINDER AND CONTAINER STORAG217/15/20199/9/2019