Brothers of Mercy Nursing & Rehabilitation Center

Brothers of Mercy Nursing & Rehabilitation Center

10570 Bergtold Road

Clarence, NY 14031

7167596985

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: 86%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain0.952412/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened0.394612/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine96.885212/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine98.885112/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication2.171012/1/2017
471Percentage of short-stay residents who made improvements in function42.452812/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased13.872012/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain1.557412/1/2017
403Percentage of high risk long-stay residents with pressure ulcers3.963412/1/2017
404Percentage of long-stay residents who lose too much weight3.478312/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder58.671612/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder1.054212/1/2017
407Percentage of long-stay residents with a urinary tract infection1.662012/1/2017
408Percentage of long-stay residents who have depressive symptoms3.239412/1/2017
409Percentage of long-stay residents who were physically restrained0.000012/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury0.965512/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine99.463812/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine100.000012/1/2017
419Percentage of long-stay residents who received an antipsychotic medication8.391612/1/2017
451Percentage of long-stay residents whose ability to move independently worsened29.045412/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication16.477312/1/2017

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):49
Intakes received per 100 occupied beds (last three years):22.5
Percent of total intakes received that were facility self reported incidents (last three years):86
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
11/24/2014Certification2
12/23/2015Certification2
2/7/2017Certification2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthDIGNITY AND RESPECT OF INDIVIDUALITY2111/24/20141/20/2015
HealthCOMPREHENSIVE ASSESSMENTS2111/24/20141/20/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS2111/24/20141/20/2015
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY2211/24/20141/20/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE2211/24/20141/20/2015
LSCLIFE SAFETY CODE STANDARD2211/24/20141/23/2015
HealthHOUSEKEEPING & MAINTENANCE SERVICES2112/23/20152/15/2016
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2112/23/20152/15/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES2212/23/20152/15/2016
HealthPROVIDE/OBTAIN SPECIALIZED REHAB SERVICES2112/23/20152/15/2016
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
LSCHazardous Areas - Enclosure222/7/20173/27/2017
LSCElectrical Systems - Essential Electric Syste222/7/20173/27/2017
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES212/7/20174/3/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES222/7/20174/3/2017
LSCEgress Doors222/7/20174/7/2017