Brothers of Mercy Nursing & Rehabilitation Center
10570 Bergtold Road
Clarence, NY 14031
7167596985
http:brothersofmercy.org/Services: Baseline Services, Outpatient/Occupational Therapy, Outpatient/Physical Therapy, Outpatient/Speech Language Pathology Therapy
| Behavioral Intervention: | |
| Pediatric: | |
| Pediatric Ventilator Dependent: | |
| Residential Health Care: | 240 |
| Transitional Care Unit: | |
| Ventilator Dependent: | |
| Total Number of Beds: | 240 |
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
Employee Flu Vaccination Rate: 88%
Occupancy Rate: 95%
| Measure Code | Measure Description | Average Score | Footnote | Processing Date |
|---|---|---|---|---|
| 430 | Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2800 | 11/1/2019 | |
| 434 | Percentage of short-stay residents who newly received an antipsychotic medication | 1.4800 | 11/1/2019 | |
| 471 | Percentage of short-stay residents who made improvements in function | 46.7700 | 11/1/2019 |
| Measure Code | Measure Description | Average Score | Footnote | Processing Date |
|---|---|---|---|---|
| 401 | Percentage of long-stay residents whose need for help with daily activities has increased | 17.8000 | 11/1/2019 | |
| 404 | Percentage of long-stay residents who lose too much weight | 4.4400 | 11/1/2019 | |
| 405 | Percentage of low risk long-stay residents who lose control of their bowels or bladder | 59.2700 | 11/1/2019 | |
| 406 | Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4400 | 11/1/2019 | |
| 407 | Percentage of long-stay residents with a urinary tract infection | 1.4300 | 11/1/2019 | |
| 408 | Percentage of long-stay residents who have depressive symptoms | 4.3500 | 11/1/2019 | |
| 409 | Percentage of long-stay residents who were physically restrained | 0.0000 | 11/1/2019 | |
| 410 | Percentage of long-stay residents experiencing one or more falls with major injury | 1.2900 | 11/1/2019 | |
| 415 | Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7100 | 11/1/2019 | |
| 419 | Percentage of long-stay residents who received an antipsychotic medication | 7.3400 | 11/1/2019 | |
| 451 | Percentage of long-stay residents whose ability to move independently worsened | 24.1600 | 11/1/2019 | |
| 452 | Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.9200 | 11/1/2019 |
| Number of Standard Health Deficiencies: | 8 |
| Number of Live Safety Code Deficiencies: | 11 |
| Number of Total Deficiencies: | 19 |
| 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): | 22.2 |
| Percent of total intakes received that were facility self reported incidents (last three years): | 88 |
| 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 |
| Survey Date | Deficiency Category | Stipulation Date | Fine Assessed |
|---|
| Initial Survey Date | Survey Type | Total Visits Required |
|---|---|---|
| 12/23/2015 | CERTIFICATION | 2 |
| 2/7/2017 | CERTIFICATION/COMPLAINT | 2 |
| 6/5/2018 | CERTIFICATION/COMPLAINT | 2 |
| 7/15/2019 | CERTIFICATION | 2 |
| Inspection Type | Deficiency | Severity | Residents Affected | Date of Initial Survey | Date Citation Corrected |
|---|---|---|---|---|---|
| Health | ADL CARE PROVIDED FOR DEPENDENT RESIDENTS | 2 | 1 | 7/15/2019 | 2/15/2016 |
| Health | HOUSEKEEPING & MAINTENANCE SERVICES | 2 | 1 | 7/15/2019 | 2/15/2016 |
| Health | PROVIDE/OBTAIN SPECIALIZED REHAB SERVICES | 2 | 1 | 7/15/2019 | 2/15/2016 |
| Health | TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES | 2 | 2 | 7/15/2019 | 2/15/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 7/15/2019 | 2/15/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 7/15/2019 | 2/15/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 7/15/2019 | 2/15/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 7/15/2019 | 2/15/2016 |
| LSC | ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE | 2 | 2 | 7/15/2019 | 3/27/2017 |
| LSC | HAZARDOUS AREAS - ENCLOSURE | 2 | 2 | 7/15/2019 | 3/27/2017 |
| Health | FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES | 2 | 2 | 7/15/2019 | 4/3/2017 |
| Health | RIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES | 2 | 1 | 7/15/2019 | 4/3/2017 |
| LSC | EGRESS DOORS | 2 | 2 | 7/15/2019 | 4/7/2017 |
| Health | TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER | 2 | 1 | 7/15/2019 | 8/1/2018 |
| Health | TUBE FEEDING MGMT/RESTORE EATING SKILLS | 2 | 1 | 7/15/2019 | 9/9/2019 |
| LSC | DOORS WITH SELF-CLOSING DEVICES | 2 | 1 | 7/15/2019 | 9/9/2019 |
| LSC | ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS | 2 | 2 | 7/15/2019 | 9/9/2019 |
| LSC | ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE | 2 | 1 | 7/15/2019 | 9/9/2019 |
| LSC | GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG | 2 | 1 | 7/15/2019 | 9/9/2019 |
