Mercy Hospital Skilled Nursing Facility

Mercy Hospital Skilled Nursing Facility

55 Melroy Avenue

Lackawanna, NY 14218

7168282300

www.chsbuffalo.org/Facilities/NursingHomes/MercySNF

Services: Baseline Services, Clinical Laboratory Service, Radiology - Diagnostic

Beds

Behavioral Intervention:
Pediatric:
Pediatric Ventilator Dependent:
Residential Health Care:84
Transitional Care Unit:
Ventilator Dependent:
Total Number of Beds:84

Administrative

Ownership: Proprietary--Business Corporation

Operated by: Catholic Health System, Inc.
144 Genesee Street Seton Prof
Buffalo, NY 14203

Permanent Facility Identifier: 214

Operating Certificate: 1401008N

Medicaid Certified

Medicare Certified

Medicare Number: 335308

Statistics

Employee Flu Vaccination Rate: 30%

Occupancy Rate: 100%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain2.56410000000000039/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened09/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine1009/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine96.363639/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication0The number of residents is too small to report. Call the facility to discuss this quality measure.9/1/2017
471Percentage of short-stay residents who made improvements in function0The number of residents is too small to report. Call the facility to discuss this quality measure.9/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased10.431652009/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain3.825728009/1/2017
403Percentage of high risk long-stay residents with pressure ulcers4.635763009/1/2017
404Percentage of long-stay residents who lose too much weight5.590063009/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder65.573771009/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder0.215595009/1/2017
407Percentage of long-stay residents with a urinary tract infection2.760735009/1/2017
408Percentage of long-stay residents who have depressive symptoms0.630914009/1/2017
409Percentage of long-stay residents who were physically restrained0.000000009/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury5.214724009/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine99.152542009/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine99.693251009/1/2017
419Percentage of long-stay residents who received an antipsychotic medication9.815953009/1/2017
451Percentage of long-stay residents whose ability to move independently worsened23.724610009/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication15.483868009/1/2017

Complaints

Number of Standard Health Deficiencies:26
Number of Live Safety Code Deficiencies:14
Number of Total Deficiencies:40
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):9
Intakes received per 100 occupied beds (last three years):10.8
Percent of total intakes received that were facility self reported incidents (last three years):89
On-site complaint investigations (last three years):3
Complaint investigations resulting in citations (last three years):1
Complaint investigations resulting in citations per 100 occupied beds (last three years):1.2
Complaint Citations in deficiency category: Administration:0
Complaint Citations in deficiency category: Quality of Care:1
Complaint Citations in deficiency category: Resident Rights:0
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
8/6/2015Certification2
9/11/2013Certification2
9/12/2016Certification2
9/5/2014Certification2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate citation corrected
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP11
LSCLIFE SAFETY CODE STANDARD2110/14/2016
LSCLIFE SAFETY CODE STANDARD2210/14/2016
LSCLIFE SAFETY CODE STANDARD2210/14/2016
LSCLIFE SAFETY CODE STANDARD2210/14/2016
LSCLIFE SAFETY CODE STANDARD2210/14/2016
LSCLIFE SAFETY CODE STANDARD2210/24/2013
LSCLIFE SAFETY CODE STANDARD2110/24/2014
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS2110/24/2014
LSCLIFE SAFETY CODE STANDARD2210/24/2014
LSCLIFE SAFETY CODE STANDARD2210/24/2014
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING2110/24/2014
HealthTREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS2110/24/2014
HealthDEVELOP COMPREHENSIVE CARE PLANS2110/28/2016
HealthTREATMENT/CARE FOR SPECIAL NEEDS2110/28/2016
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE2110/28/2016
LSCLIFE SAFETY CODE STANDARD2210/4/2013
HealthRequirements Before Submitting a Request for2110/7/2016
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)2111/8/2013
HealthDIGNITY AND RESPECT OF INDIVIDUALITY2111/8/2013
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES2111/8/2013
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT2111/8/2013
HealthCOMPREHENSIVE ASSESSMENTS2111/8/2013
HealthDEVELOP COMPREHENSIVE CARE PLANS2111/8/2013
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP2111/8/2013
HealthSERVICES BY QUALIFIED PERSONS/PER CARE PLAN2111/8/2013
HealthTREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS2111/8/2013
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2111/8/2013
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES2111/8/2013
HealthINCREASE/PREVENT DECREASE IN RANGE OF MOTION2111/8/2013
HealthROUTINE/EMERGENCY DENTAL SERVICES IN SNFS2111/8/2013
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS2111/8/2013
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE2111/8/2013
LSCLIFE SAFETY CODE STANDARD229/25/2013
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS219/25/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING219/25/2015
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES219/25/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE129/25/2015
LSCLIFE SAFETY CODE STANDARD229/29/2014
LSCLIFE SAFETY CODE STANDARD229/29/2014
LSCLIFE SAFETY CODE STANDARD229/29/2014