Buffalo Community Healthcare Center

Buffalo Community Healthcare Center

1205 Delaware Avenue

Buffalo, NY 14209

7168853838

www.pscwny.org/harbour-hawthorn-home.html

Services: Baseline Services

Beds

Behavioral Intervention:
Pediatric:
Pediatric Ventilator Dependent:
Residential Health Care:95
Transitional Care Unit:
Ventilator Dependent:
Total Number of Beds:95

Administrative

Ownership: Proprietary--LLC

Operated by: EN Receiver, LLC
1205 Delaware Avenue
Buffalo, NY 14209

Permanent Facility Identifier: 633

Operating Certificate: 1401339N

Medicaid Certified

Medicare Certified

Medicare Number: 335640

Statistics

Employee Flu Vaccination Rate: 64%

Occupancy Rate: 95%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain14.29002/1/2019
425Percentage of short-stay residents with pressure ulcers that are new or worsened4.21002/1/2019
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine47.27002/1/2019
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine32.73002/1/2019
434Percentage of short-stay residents who newly received an antipsychotic medication1.01002/1/2019
471Percentage of short-stay residents who made improvements in function65.26002/1/2019

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased31.03002/1/2019
402Percentage of long-stay residents who self-report moderate to severe pain5.76002/1/2019
403Percentage of high risk long-stay residents with pressure ulcers14.29002/1/2019
404Percentage of long-stay residents who lose too much weight8.82002/1/2019
405Percentage of low risk long-stay residents who lose control of their bowels or bladder25.84002/1/2019
406Percentage of long-stay residents with a catheter inserted and left in their bladder3.10002/1/2019
407Percentage of long-stay residents with a urinary tract infection2.08002/1/2019
408Percentage of long-stay residents who have depressive symptoms0.45002/1/2019
409Percentage of long-stay residents who were physically restrained0.00002/1/2019
410Percentage of long-stay residents experiencing one or more falls with major injury3.29002/1/2019
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine71.38002/1/2019
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine62.96002/1/2019
419Percentage of long-stay residents who received an antipsychotic medication9.73002/1/2019
451Percentage of long-stay residents whose ability to move independently worsened30.24002/1/2019
452Percentage of long-stay residents who received an antianxiety or hypnotic medication16.53002/1/2019

Complaints

Number of Standard Health Deficiencies:85
Number of Live Safety Code Deficiencies:56
Number of Total Deficiencies:141
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:3
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :2
Total intakes received (last three years):87
Intakes received per 100 occupied beds (last three years):96.7
Percent of total intakes received that were facility self reported incidents (last three years):46
On-site complaint investigations (last three years):21
Complaint investigations resulting in citations (last three years):13
Complaint investigations resulting in citations per 100 occupied beds (last three years):14.4
Complaint Citations in deficiency category: Administration:2
Complaint Citations in deficiency category: Quality of Care:6
Complaint Citations in deficiency category: Resident Rights:2
Complaint Citations in deficiency category: Dietary Services:0
Complaint Citations in deficiency category: Physical Environment:1
Complaint Citations in deficiency category: Other Services:1
Complaint Citations across all deficiency categories (last three years):12

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed
Quality of Care13-Feb-0810000
Multiple Deficiencies24-Sep-182000
17-Jun-13Quality of Care9-Aug-1710000
24-Jan-17Multiple Deficiencies19-Jun-176000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
1/18/2018COMPLAINT2
1/24/2017CERTIFICATION/COMPLAINT3
10/4/2018COMPLAINT2
12/5/2014COMPLAINT1
3/8/2016CERTIFICATION/COMPLAINT2
4/24/2015CERTIFICATION/COMPLAINT2
4/25/2018CERTIFICATION/COMPLAINT2
5/15/2015COMPLAINT2
9/10/2015COMPLAINT2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthHOUSEKEEPING & MAINTENANCE SERVICES1112/5/2014
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE114/24/2015
HealthNOTICE OF RIGHTS, RULES, SERVICES, CHARGES111/24/2017
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS219/10/201510/29/2015
HealthINVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION2110/4/201811/30/2018
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES211/18/20182/28/2018
LSCSPRINKLER SYSTEM - INSTALLATION211/24/20173/23/2017
HealthASSISTIVE DEVICES - EATING EQUIPMENT/UTENSILS211/24/20173/24/2017
HealthDIGNITY AND RESPECT OF INDIVIDUALITY211/24/20173/24/2017
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS211/24/20173/24/2017
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS211/24/20173/24/2017
HealthHOUSEKEEPING & MAINTENANCE SERVICES121/24/20173/24/2017
HealthLISTEN/ACT ON GROUP GRIEVANCE/RECOMMENDATION221/24/20173/24/2017
HealthMAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE221/24/20173/24/2017
HealthMAINTAINS EFFECTIVE PEST CONTROL PROGRAM221/24/20173/24/2017
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER211/24/20173/24/2017
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING211/24/20173/24/2017
HealthPROVISION OF MEDICALLY RELATED SOCIAL SERVICE221/24/20173/24/2017
HealthREASONABLE ACCOMMODATION OF NEEDS/PREFERENCES211/24/20173/24/2017
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE211/24/20173/24/2017
HealthRETENTION OF RESIDENT CLINICAL RECORDS121/24/20173/24/2017
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES421/24/20173/24/2017
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NH221/24/20173/24/2017
HealthSUFFICIENT DIETARY SUPPORT PERSONNEL221/24/20173/24/2017
LSCDOORS WITH SELF-CLOSING DEVICES221/24/20173/24/2017
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE221/24/20173/24/2017
LSCGAS EQUIPMENT - CYLINDER AND CONTAINER STORAG221/24/20173/24/2017
LSCGAS EQUIPMENT - PRECAUTIONS FOR HANDLING OXYG211/24/20173/24/2017
LSCGENERAL REQUIREMENTS - OTHER221/24/20173/24/2017
LSCMEANS OF EGRESS - GENERAL211/24/20173/24/2017
LSCPORTABLE FIRE EXTINGUISHERS221/24/20173/24/2017
LSCPORTABLE SPACE HEATERS211/24/20173/24/2017
LSCSUBDIVISION OF BUILDING SPACES - SMOKE BARRIE221/24/20173/24/2017
LSCVERTICAL OPENINGS - ENCLOSURE211/24/20173/24/2017
HealthCOMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE223/8/20164/20/2016
HealthCOMPREHENSIVE ASSESS AT LEAST EVERY 12 MONTHS223/8/20164/20/2016
HealthCOMPREHENSIVE ASSESSMENT 14 DAYS AFTER ADMIT223/8/20164/20/2016
HealthDEPARTMENT CRIMINAL HISTORY REVIEW213/8/20164/20/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS213/8/20164/20/2016
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS213/8/20164/20/2016
HealthENCODING/TRANSMITTING RESIDENT ASSESSMENT213/8/20164/20/2016
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES213/8/20164/20/2016
HealthHOUSEKEEPING & MAINTENANCE SERVICES223/8/20164/20/2016
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS213/8/20164/20/2016
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER223/8/20164/20/2016
HealthPHYSICAL ENVIRONMENT223/8/20164/20/2016
HealthPROVIDE/OBTAIN SPECIALIZED REHAB SERVICES223/8/20164/20/2016
HealthQUARTERLY ASSESSMENT AT LEAST EVERY 3 MONTHS223/8/20164/20/2016
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE213/8/20164/20/2016
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES223/8/20164/20/2016
HealthSERVICES PROVIDED MEET PROFESSIONAL STANDARDS213/8/20164/20/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES213/8/20164/20/2016
HealthTX/SVC FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD213/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD213/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD213/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NH223/8/20165/16/2016
HealthSTANDARDS OF CONSTRUCTION FOR NEW NH223/8/20165/16/2016
LSCLIFE SAFETY CODE STANDARD223/8/20165/16/2016
LSCLIFE SAFETY CODE STANDARD223/8/20165/16/2016
LSCLIFE SAFETY CODE STANDARD213/8/20165/6/2016
HealthEFFECTIVE ADMINISTRATION/RESIDENT WELL-BEING421/24/20175/8/2017
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION221/24/20175/8/2017
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY221/24/20175/8/2017
HealthPHYSICAL ENVIRONMENT221/24/20175/8/2017
HealthQAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS421/24/20175/8/2017
LSCBUILDING CONSTRUCTION TYPE AND HEIGHT221/24/20175/8/2017
LSCCORRIDOR - DOORS221/24/20175/8/2017
LSCELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS221/24/20175/8/2017
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE211/24/20175/8/2017
LSCELECTRICAL SYSTEMS - OTHER211/24/20175/8/2017
LSCHAZARDOUS AREAS - ENCLOSURE221/24/20175/8/2017
LSCHVAC221/24/20175/8/2017
LSCSPRINKLER SYSTEM - MAINTENANCE AND TESTING221/24/20175/8/2017
HealthACCOUNTING AND RECORDS OF PERSONAL FUNDS124/25/20186/22/2018
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS214/25/20186/22/2018
HealthBASELINE CARE PLAN214/25/20186/22/2018
HealthCOMPREHENSIVE ASSESSMENTS & TIMING214/25/20186/22/2018
HealthDEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN214/25/20186/22/2018
HealthDIALYSIS214/25/20186/22/2018
HealthDRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON224/25/20186/22/2018
HealthFREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE214/25/20186/22/2018
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES224/25/20186/22/2018
HealthINFECTION CONTROL224/25/20186/22/2018
HealthINFECTION PREVENTION & CONTROL224/25/20186/22/2018
HealthINFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS214/25/20186/22/2018
HealthPHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS224/25/20186/22/2018
HealthPROTECTION/MANAGEMENT OF PERSONAL FUNDS214/25/20186/22/2018
HealthQRTLY ASSESSMENT AT LEAST EVERY 3 MONTHS214/25/20186/22/2018
HealthQUALITY OF CARE214/25/20186/22/2018
HealthREASONABLE ACCOMMODATIONS NEEDS/PREFERENCES214/25/20186/22/2018
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT124/25/20186/22/2018
HealthSTANDARDS OF CONSTRUCTION FOR NEW NH224/25/20186/22/2018
LSCBUILDING CONSTRUCTION TYPE AND HEIGHT224/25/20186/22/2018
LSCCOOKING FACILITIES224/25/20186/22/2018
LSCELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS224/25/20186/22/2018
LSCELECTRICAL EQUIPMENT - TESTING AND MAINTENANC224/25/20186/22/2018
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE224/25/20186/22/2018
LSCELEVATORS224/25/20186/22/2018
LSCEP PROGRAM PATIENT POPULATION134/25/20186/22/2018
LSCEP TRAINING PROGRAM134/25/20186/22/2018
LSCFIRE ALARM SYSTEM - TESTING AND MAINTENANCE224/25/20186/22/2018
LSCFIRE DRILLS224/25/20186/22/2018
LSCGAS EQUIPMENT - CYLINDER AND CONTAINER STORAG224/25/20186/22/2018
LSCHVAC224/25/20186/22/2018
LSCPORTABLE FIRE EXTINGUISHERS224/25/20186/22/2018
LSCSPRINKLER SYSTEM - MAINTENANCE AND TESTING224/25/20186/22/2018
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS214/24/20156/24/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS214/24/20156/24/2015
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES214/24/20156/24/2015
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER214/24/20156/24/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING214/24/20156/24/2015
HealthPROVISION OF MEDICALLY RELATED SOCIAL SERVICE214/24/20156/24/2015
HealthRIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE214/24/20156/24/2015
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP214/24/20156/24/2015
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES224/24/20156/24/2015
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT214/24/20156/24/2015
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES214/24/20156/24/2015
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NH224/24/20156/24/2015
HealthTREATMENT/DEVICES TO MAINTAIN HEARING/VISION214/24/20156/24/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES214/24/20156/24/2015
HealthTX/SVC FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES214/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD214/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD224/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD224/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD224/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD224/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD224/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD234/24/20156/24/2015
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)215/15/20157/24/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES215/15/20157/24/2015