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: 88%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain0.55002/1/2019
425Percentage of short-stay residents with pressure ulcers that are new or worsened1.03002/1/2019
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine97.11002/1/2019
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine98.93002/1/2019
434Percentage of short-stay residents who newly received an antipsychotic medication0.79002/1/2019
471Percentage of short-stay residents who made improvements in function55.50002/1/2019

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased18.71002/1/2019
402Percentage of long-stay residents who self-report moderate to severe pain1.89002/1/2019
403Percentage of high risk long-stay residents with pressure ulcers4.64002/1/2019
404Percentage of long-stay residents who lose too much weight5.37002/1/2019
405Percentage of low risk long-stay residents who lose control of their bowels or bladder66.05002/1/2019
406Percentage of long-stay residents with a catheter inserted and left in their bladder1.78002/1/2019
407Percentage of long-stay residents with a urinary tract infection0.87002/1/2019
408Percentage of long-stay residents who have depressive symptoms5.17002/1/2019
409Percentage of long-stay residents who were physically restrained0.00002/1/2019
410Percentage of long-stay residents experiencing one or more falls with major injury1.01002/1/2019
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine99.86002/1/2019
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine99.86002/1/2019
419Percentage of long-stay residents who received an antipsychotic medication9.41002/1/2019
451Percentage of long-stay residents whose ability to move independently worsened28.48002/1/2019
452Percentage of long-stay residents who received an antianxiety or hypnotic medication14.81002/1/2019

Complaints

Number of Standard Health Deficiencies:7
Number of Live Safety Code Deficiencies:7
Number of Total Deficiencies:14
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):44
Intakes received per 100 occupied beds (last three years):21.0
Percent of total intakes received that were facility self reported incidents (last three years):84
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

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2112/23/20152/15/2016
HealthHOUSEKEEPING & MAINTENANCE SERVICES2112/23/20152/15/2016
HealthPROVIDE/OBTAIN SPECIALIZED REHAB SERVICES2112/23/20152/15/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES2212/23/20152/15/2016
LSCLIFE SAFETY CODE STANDARD2212/23/20152/15/2016
LSCLIFE SAFETY CODE STANDARD2212/23/20152/15/2016
LSCLIFE SAFETY CODE STANDARD2212/23/20152/15/2016
LSCLIFE SAFETY CODE STANDARD2212/23/20152/15/2016
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE222/7/20173/27/2017
LSCHAZARDOUS AREAS - ENCLOSURE222/7/20173/27/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES222/7/20174/3/2017
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES212/7/20174/3/2017
LSCEGRESS DOORS222/7/20174/7/2017
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER216/5/20188/1/2018