Brothers of Mercy Nursing & Rehabilitation Center

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

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: 89%

Occupancy Rate: 89%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine98.58809/1/2020
434Percentage of short-stay residents who newly received an antipsychotic medication0.83109/1/2020
471Percentage of short-stay residents who made improvements in function49.03609/1/2020

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased11.684011/1/2019
404Percentage of long-stay residents who lose too much weight5.709011/1/2019
405Percentage of low risk long-stay residents who lose control of their bowels or bladder62.151011/1/2019
406Percentage of long-stay residents with a catheter inserted and left in their bladder1.397011/1/2019
407Percentage of long-stay residents with a urinary tract infection2.006011/1/2019
408Percentage of long-stay residents who have depressive symptoms4.348011/1/2019
409Percentage of long-stay residents who were physically restrained0.000011/1/2019
410Percentage of long-stay residents experiencing one or more falls with major injury2.000011/1/2019
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine99.857011/1/2019
419Percentage of long-stay residents who received an antipsychotic medication8.309011/1/2019
451Percentage of long-stay residents whose ability to move independently worsened20.098011/1/2019
452Percentage of long-stay residents who received an antianxiety or hypnotic medication12.006011/1/2019

Complaints

Number of Standard Health Deficiencies:4
Number of Live Safety Code Deficiencies:7
Number of Total Deficiencies:11
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):52
Intakes received per 100 occupied beds (last three years):23.6
Percent of total intakes received that were facility self reported incidents (last three years):87
On-site complaint investigations (last three years):15
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):2

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
2/7/2017CERTIFICATION/COMPLAINT2
5/26/2020COMPLAINT1
6/5/2018CERTIFICATION/COMPLAINT2
7/15/2019CERTIFICATION2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE227/15/20193/27/2017
LSCHAZARDOUS AREAS - ENCLOSURE227/15/20193/27/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES227/15/20194/3/2017
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES217/15/20194/3/2017
LSCEGRESS DOORS227/15/20194/7/2017
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER217/15/20198/1/2018
HealthTUBE FEEDING MGMT/RESTORE EATING SKILLS217/15/20199/9/2019
LSCDOORS WITH SELF-CLOSING DEVICES217/15/20199/9/2019
LSCELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS227/15/20199/9/2019
LSCELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE217/15/20199/9/2019
LSCGAS EQUIPMENT - CYLINDER AND CONTAINER STORAG217/15/20199/9/2019