Mercy Hospital Skilled Nursing Facility

Mercy Hospital Skilled Nursing Facility

55 Melroy Avenue

Lackawanna, NY 14218

(716) 828-2300

www.chsbuffalo.org/Facilities/NursingHomes/MercySNF

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

Beds

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

Administrative

Ownership: Voluntary--Not for Profit Corporation

Operated by: Mercy Hospital of Buffalo Inc
565 Abbott Road
Buffalo, NY 14220

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 pain103/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened03/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine1003/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine95.555553/1/2017
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.3/1/2017
471Percentage of short-stay residents who made improvements in function0The data for this measure is missing. Call the facility to discuss this quality measure.3/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased9.574467003/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain2.665279003/1/2017
403Percentage of high risk long-stay residents with pressure ulcers3.883494003/1/2017
404Percentage of long-stay residents who lose too much weight5.521473003/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder59.130437003/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder0.211540003/1/2017
407Percentage of long-stay residents with a urinary tract infection2.424242003/1/2017
408Percentage of long-stay residents who have depressive symptoms1.567397003/1/2017
409Percentage of long-stay residents who were physically restrained0.000000003/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury5.151515003/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine99.150141003/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine99.696970003/1/2017
419Percentage of long-stay residents who received an antipsychotic medication10.606059003/1/2017
451Percentage of long-stay residents whose ability to move independently worsened16.289961003/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication15.189872003/1/2017

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):12
Intakes received per 100 occupied beds (last three years):14.3
Percent of total intakes received that were facility self reported incidents (last three years):92
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
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN11
LSCEMERGENCY LIGHTING2210/14/2016
LSCEXISTING ELEVATOR REQUIREMENTS2210/14/2016
LSCCOMMON WALL2110/14/2016
LSCSPRINKLER SYSTEM MAINTENANCE2210/14/2016
LSCTESTING OF FIRE ALARM2210/14/2016
LSCAUTOMATIC SPRINKLER SYSTEM2210/24/2013
LSCAUTOMATIC SPRINKLER SYSTEM2110/24/2014
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS2110/24/2014
HealthRESIDENT GIVEN TREATMENT TO IMPROVE/MAINTAIN ADLS2110/24/2014
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING2110/24/2014
LSCSTAIRS AND SMOKE PROOF TOWERS2210/24/2014
LSCHAZARDOUS AREAS - SEPARATION2210/24/2014
HealthDEVELOP COMPREHENSIVE CARE PLANS2110/28/2016
HealthPROPER TREATMENT/CARE FOR SPECIAL CARE NEEDS2110/28/2016
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS2110/28/2016
LSCMEDICAL GAS SYSTEM2210/4/2013
HealthCRIMINAL HISTORY RECORD CHECK SUBJECT'S SIGNED INFORMED CONSENT REQUIRED2110/7/2016
HealthSERVICES BY QUALIFIED PERSONS IN ACCORDANCE WITH CARE PLAN2111/8/2013
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN2111/8/2013
HealthRESIDENT GIVEN TREATMENT TO IMPROVE/MAINTAIN ADLS2111/8/2013
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2111/8/2013
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES2111/8/2013
HealthRANGE OF MOTION TREATMENT AND SERVICES2111/8/2013
HealthDENTAL SERVICES IN SKILLED NURSING FACILITIES2111/8/2013
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM2111/8/2013
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS2111/8/2013
HealthDEVELOP COMPREHENSIVE CARE PLANS2111/8/2013
HealthCOMPREHENSIVE ASSESSMENTS2111/8/2013
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT2111/8/2013
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES2111/8/2013
HealthDIGNITY2111/8/2013
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.2111/8/2013
LSCHAZARDOUS AREAS - SEPARATION229/25/2013
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE219/25/2015
HealthFACILITY IS FREE OF ACCIDENT HAZARDS219/25/2015
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS129/25/2015
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING219/25/2015
LSCSPRINKLER SYSTEM MAINTENANCE229/29/2014
LSCFIRE DRILLS229/29/2014
LSCMEDICAL GAS SYSTEM229/29/2014