Buffalo Community Healthcare Center
1205 Delaware Avenue
Buffalo, NY 14209
7168853838
Services: Baseline Services
| Behavioral Intervention: | |
| Pediatric: | |
| Pediatric Ventilator Dependent: | |
| Residential Health Care: | 95 |
| Transitional Care Unit: | |
| Ventilator Dependent: | |
| Total Number of Beds: | 95 |
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
Employee Flu Vaccination Rate: 64%
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 | 28.6400 | 11/1/2019 | |
| 434 | Percentage of short-stay residents who newly received an antipsychotic medication | 6.5200 | 11/1/2019 | |
| 471 | Percentage of short-stay residents who made improvements in function | 61.3700 | 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 | 28.2900 | 11/1/2019 | |
| 404 | Percentage of long-stay residents who lose too much weight | 3.9100 | 11/1/2019 | |
| 405 | Percentage of low risk long-stay residents who lose control of their bowels or bladder | 25.7100 | 11/1/2019 | |
| 406 | Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6700 | 11/1/2019 | |
| 407 | Percentage of long-stay residents with a urinary tract infection | 1.0800 | 11/1/2019 | |
| 408 | Percentage of long-stay residents who have depressive symptoms | 21.6500 | 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 | 0.7100 | 11/1/2019 | |
| 415 | Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 40.0700 | 11/1/2019 | |
| 419 | Percentage of long-stay residents who received an antipsychotic medication | 7.2100 | 11/1/2019 | |
| 451 | Percentage of long-stay residents whose ability to move independently worsened | 33.6100 | 11/1/2019 | |
| 452 | Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.9100 | 11/1/2019 |
| Number of Standard Health Deficiencies: | 76 |
| Number of Live Safety Code Deficiencies: | 65 |
| 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): | 133 |
| Intakes received per 100 occupied beds (last three years): | 155.8 |
| Percent of total intakes received that were facility self reported incidents (last three years): | 54 |
| On-site complaint investigations (last three years): | 24 |
| Complaint investigations resulting in citations (last three years): | 11 |
| Complaint investigations resulting in citations per 100 occupied beds (last three years): | 12.9 |
| Complaint Citations in deficiency category: Administration: | 2 |
| Complaint Citations in deficiency category: Quality of Care: | 5 |
| 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): | 11 |
| Survey Date | Deficiency Category | Stipulation Date | Fine Assessed |
|---|---|---|---|
| . | Quality of Care | 2/13/2008 | 10000 |
| . | Multiple Deficiencies | 9/24/2018 | 2000 |
| 1/24/2017 | Multiple Deficiencies | 6/19/2017 | 6000 |
| 6/17/2013 | Quality of Care | 8/9/2017 | 10000 |
| Initial Survey Date | Survey Type | Total Visits Required |
|---|---|---|
| 1/15/2019 | COMPLAINT | 2 |
| 1/18/2018 | COMPLAINT | 2 |
| 1/24/2017 | CERTIFICATION/COMPLAINT | 3 |
| 10/4/2018 | COMPLAINT | 2 |
| 3/8/2016 | CERTIFICATION/COMPLAINT | 2 |
| 4/25/2018 | CERTIFICATION/COMPLAINT | 2 |
| 6/12/2019 | CERTIFICATION/COMPLAINT | 2 |
| Inspection Type | Deficiency | Severity | Residents Affected | Date of Initial Survey | Date Citation Corrected |
|---|---|---|---|---|---|
| Health | NOTICE OF RIGHTS, RULES, SERVICES, CHARGES | 1 | 1 | 10/4/2018 | . |
| Health | INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION | 2 | 1 | 10/4/2018 | 11/30/2018 |
| Health | FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES | 2 | 1 | 10/4/2018 | 2/28/2018 |
| Health | NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.) | 2 | 1 | 10/4/2018 | 3/11/2019 |
| Health | RESIDENTS ARE FREE OF SIGNIFICANT MED ERRORS | 2 | 1 | 10/4/2018 | 3/11/2019 |
| LSC | SPRINKLER SYSTEM - INSTALLATION | 2 | 1 | 10/4/2018 | 3/23/2017 |
| Health | ASSISTIVE DEVICES - EATING EQUIPMENT/UTENSILS | 2 | 1 | 10/4/2018 | 3/24/2017 |
| Health | DIGNITY AND RESPECT OF INDIVIDUALITY | 2 | 1 | 10/4/2018 | 3/24/2017 |
| Health | DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS | 2 | 1 | 10/4/2018 | 3/24/2017 |
| Health | DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS | 2 | 1 | 10/4/2018 | 3/24/2017 |
| Health | HOUSEKEEPING & MAINTENANCE SERVICES | 1 | 2 | 10/4/2018 | 3/24/2017 |
| Health | LISTEN/ACT ON GROUP GRIEVANCE/RECOMMENDATION | 2 | 2 | 10/4/2018 | 3/24/2017 |
| Health | MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE | 2 | 2 | 10/4/2018 | 3/24/2017 |
| Health | MAINTAINS EFFECTIVE PEST CONTROL PROGRAM | 2 | 2 | 10/4/2018 | 3/24/2017 |
| Health | NO CATHETER, PREVENT UTI, RESTORE BLADDER | 2 | 1 | 10/4/2018 | 3/24/2017 |
| Health | PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING | 2 | 1 | 10/4/2018 | 3/24/2017 |
| Health | PROVISION OF MEDICALLY RELATED SOCIAL SERVICE | 2 | 2 | 10/4/2018 | 3/24/2017 |
| Health | REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES | 2 | 1 | 10/4/2018 | 3/24/2017 |
| Health | RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE | 2 | 1 | 10/4/2018 | 3/24/2017 |
| Health | RETENTION OF RESIDENT CLINICAL RECORDS | 1 | 2 | 10/4/2018 | 3/24/2017 |
| Health | RIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES | 4 | 2 | 10/4/2018 | 3/24/2017 |
| Health | STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH | 2 | 2 | 10/4/2018 | 3/24/2017 |
| Health | SUFFICIENT DIETARY SUPPORT PERSONNEL | 2 | 2 | 10/4/2018 | 3/24/2017 |
| LSC | DOORS WITH SELF-CLOSING DEVICES | 2 | 2 | 10/4/2018 | 3/24/2017 |
| LSC | ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE | 2 | 2 | 10/4/2018 | 3/24/2017 |
| LSC | GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG | 2 | 2 | 10/4/2018 | 3/24/2017 |
| LSC | GAS EQUIPMENT - PRECAUTIONS FOR HANDLING OXYG | 2 | 1 | 10/4/2018 | 3/24/2017 |
| LSC | GENERAL REQUIREMENTS - OTHER | 2 | 2 | 10/4/2018 | 3/24/2017 |
| LSC | MEANS OF EGRESS - GENERAL | 2 | 1 | 10/4/2018 | 3/24/2017 |
| LSC | PORTABLE FIRE EXTINGUISHERS | 2 | 2 | 10/4/2018 | 3/24/2017 |
| LSC | PORTABLE SPACE HEATERS | 2 | 1 | 10/4/2018 | 3/24/2017 |
| LSC | SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE | 2 | 2 | 10/4/2018 | 3/24/2017 |
| LSC | VERTICAL OPENINGS - ENCLOSURE | 2 | 1 | 10/4/2018 | 3/24/2017 |
| Health | COMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE | 2 | 2 | 10/4/2018 | 4/20/2016 |
| Health | COMPREHENSIVE ASSESS AT LEAST EVERY 12 MONTHS | 2 | 2 | 10/4/2018 | 4/20/2016 |
| Health | COMPREHENSIVE ASSESSMENT 14 DAYS AFTER ADMIT | 2 | 2 | 10/4/2018 | 4/20/2016 |
| Health | DEPARTMENT CRIMINAL HISTORY REVIEW | 2 | 1 | 10/4/2018 | 4/20/2016 |
| Health | DEVELOP COMPREHENSIVE CARE PLANS | 2 | 1 | 10/4/2018 | 4/20/2016 |
| Health | DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS | 2 | 1 | 10/4/2018 | 4/20/2016 |
| Health | ENCODING/TRANSMITTING RESIDENT ASSESSMENT | 2 | 1 | 10/4/2018 | 4/20/2016 |
| Health | FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES | 2 | 1 | 10/4/2018 | 4/20/2016 |
| Health | HOUSEKEEPING & MAINTENANCE SERVICES | 2 | 2 | 10/4/2018 | 4/20/2016 |
| Health | INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS | 2 | 1 | 10/4/2018 | 4/20/2016 |
| Health | NO CATHETER, PREVENT UTI, RESTORE BLADDER | 2 | 2 | 10/4/2018 | 4/20/2016 |
| Health | PHYSICAL ENVIRONMENT | 2 | 2 | 10/4/2018 | 4/20/2016 |
| Health | PROVIDE/OBTAIN SPECIALIZED REHAB SERVICES | 2 | 2 | 10/4/2018 | 4/20/2016 |
| Health | QUARTERLY ASSESSMENT AT LEAST EVERY 3 MONTHS | 2 | 2 | 10/4/2018 | 4/20/2016 |
| Health | RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE | 2 | 1 | 10/4/2018 | 4/20/2016 |
| Health | SELF-DETERMINATION - RIGHT TO MAKE CHOICES | 2 | 2 | 10/4/2018 | 4/20/2016 |
| Health | SERVICES PROVIDED MEET PROFESSIONAL STANDARDS | 2 | 1 | 10/4/2018 | 4/20/2016 |
| Health | TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES | 2 | 1 | 10/4/2018 | 4/20/2016 |
| Health | TX/SVC FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES | 2 | 2 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 1 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 1 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 1 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 4/20/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 4/20/2016 |
| Health | STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH | 2 | 2 | 10/4/2018 | 5/16/2016 |
| Health | STANDARDS OF CONSTRUCTION FOR NEW NH | 2 | 2 | 10/4/2018 | 5/16/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 5/16/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 2 | 10/4/2018 | 5/16/2016 |
| LSC | LIFE SAFETY CODE STANDARD | 2 | 1 | 10/4/2018 | 5/6/2016 |
| Health | EFFECTIVE ADMINISTRATION/RESIDENT WELL-BEING | 4 | 2 | 10/4/2018 | 5/8/2017 |
| Health | ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION | 2 | 2 | 10/4/2018 | 5/8/2017 |
| Health | FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY | 2 | 2 | 10/4/2018 | 5/8/2017 |
| Health | PHYSICAL ENVIRONMENT | 2 | 2 | 10/4/2018 | 5/8/2017 |
| Health | QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS | 4 | 2 | 10/4/2018 | 5/8/2017 |
| LSC | BUILDING CONSTRUCTION TYPE AND HEIGHT | 2 | 2 | 10/4/2018 | 5/8/2017 |
| LSC | CORRIDOR - DOORS | 2 | 2 | 10/4/2018 | 5/8/2017 |
| LSC | ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS | 2 | 2 | 10/4/2018 | 5/8/2017 |
| LSC | ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE | 2 | 1 | 10/4/2018 | 5/8/2017 |
| LSC | ELECTRICAL SYSTEMS - OTHER | 2 | 1 | 10/4/2018 | 5/8/2017 |
| LSC | HAZARDOUS AREAS - ENCLOSURE | 2 | 2 | 10/4/2018 | 5/8/2017 |
| LSC | HVAC | 2 | 2 | 10/4/2018 | 5/8/2017 |
| LSC | SPRINKLER SYSTEM - MAINTENANCE AND TESTING | 2 | 2 | 10/4/2018 | 5/8/2017 |
| Health | ACCOUNTING AND RECORDS OF PERSONAL FUNDS | 1 | 2 | 10/4/2018 | 6/22/2018 |
| Health | ADL CARE PROVIDED FOR DEPENDENT RESIDENTS | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | BASELINE CARE PLAN | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | COMPREHENSIVE ASSESSMENTS & TIMING | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | DIALYSIS | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON | 2 | 2 | 10/4/2018 | 6/22/2018 |
| Health | FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES | 2 | 2 | 10/4/2018 | 6/22/2018 |
| Health | INFECTION CONTROL | 2 | 2 | 10/4/2018 | 6/22/2018 |
| Health | INFECTION PREVENTION & CONTROL | 2 | 2 | 10/4/2018 | 6/22/2018 |
| Health | INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS | 2 | 2 | 10/4/2018 | 6/22/2018 |
| Health | PROTECTION/MANAGEMENT OF PERSONAL FUNDS | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | QRTLY ASSESSMENT AT LEAST EVERY 3 MONTHS | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | QUALITY OF CARE | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | REASONABLE ACCOMMODATIONS NEEDS/PREFERENCES | 2 | 1 | 10/4/2018 | 6/22/2018 |
| Health | SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT | 1 | 2 | 10/4/2018 | 6/22/2018 |
| Health | STANDARDS OF CONSTRUCTION FOR NEW NH | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | BUILDING CONSTRUCTION TYPE AND HEIGHT | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | COOKING FACILITIES | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | ELEVATORS | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | EP PROGRAM PATIENT POPULATION | 1 | 3 | 10/4/2018 | 6/22/2018 |
| LSC | EP TRAINING PROGRAM | 1 | 3 | 10/4/2018 | 6/22/2018 |
| LSC | FIRE ALARM SYSTEM - TESTING AND MAINTENANCE | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | FIRE DRILLS | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | HVAC | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | PORTABLE FIRE EXTINGUISHERS | 2 | 2 | 10/4/2018 | 6/22/2018 |
| LSC | SPRINKLER SYSTEM - MAINTENANCE AND TESTING | 2 | 2 | 10/4/2018 | 6/22/2018 |
| Health | DEPARTMENT CRIMINAL HISTORY REVIEW | 2 | 2 | 10/4/2018 | 8/11/2019 |
| Health | DEVELOP/IMPLEMENT ABUSE/NEGLECT POLICIES | 2 | 2 | 10/4/2018 | 8/11/2019 |
| Health | INFECTION CONTROL | 2 | 2 | 10/4/2018 | 8/11/2019 |
| Health | LABEL/STORE DRUGS AND BIOLOGICALS | 2 | 2 | 10/4/2018 | 8/11/2019 |
| Health | LICENSE/COMPLY W/ FED/STATE/LOCL LAW/PROF STD | 1 | 3 | 10/4/2018 | 8/11/2019 |
| Health | PHYSICAL ENVIRONMENT | 2 | 2 | 10/4/2018 | 8/11/2019 |
| Health | REQUIREMENTS BEFORE SUBMITTING A REQUEST FOR | 1 | 2 | 10/4/2018 | 8/11/2019 |
| Health | RESPONSIBILITIES OF PROVIDERS; REQUIRED NOTIF | 1 | 2 | 10/4/2018 | 8/11/2019 |
| Health | SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT | 1 | 2 | 10/4/2018 | 8/11/2019 |
| LSC | BUILDING CONSTRUCTION TYPE AND HEIGHT | 2 | 2 | 10/4/2018 | 8/11/2019 |
| LSC | DEVELOP EP PLAN, REVIEW AND UPDATE ANNUALLY | 1 | 3 | 10/4/2018 | 8/11/2019 |
| LSC | ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE | 2 | 2 | 10/4/2018 | 8/11/2019 |
| LSC | ELEVATORS | 2 | 2 | 10/4/2018 | 8/11/2019 |
| LSC | EP PROGRAM PATIENT POPULATION | 1 | 3 | 10/4/2018 | 8/11/2019 |
| LSC | EP TRAINING PROGRAM | 1 | 3 | 10/4/2018 | 8/11/2019 |
| LSC | FIRE DRILLS | 2 | 2 | 10/4/2018 | 8/11/2019 |
| LSC | GAS EQUIPMENT - PRECAUTIONS FOR HANDLING OXYG | 2 | 1 | 10/4/2018 | 8/11/2019 |
| LSC | HVAC | 2 | 2 | 10/4/2018 | 8/11/2019 |
| LSC | LTC AND ICF/IID SHARING PLAN WITH PATIENTS | 1 | 3 | 10/4/2018 | 8/11/2019 |
| LSC | PLAN BASED ON ALL HAZARDS RISK ASSESSMENT | 1 | 3 | 10/4/2018 | 8/11/2019 |
| LSC | POLICIES/PROCEDURES FOR SHELTERING IN PLACE | 1 | 3 | 10/4/2018 | 8/11/2019 |
| LSC | ROLES UNDER A WAIVER DECLARED BY SECRETARY | 1 | 3 | 10/4/2018 | 8/11/2019 |
| LSC | SPRINKLER SYSTEM - MAINTENANCE AND TESTING | 2 | 2 | 10/4/2018 | 8/11/2019 |
| LSC | SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE | 2 | 2 | 10/4/2018 | 8/11/2019 |
| LSC | FIRE ALARM SYSTEM - TESTING AND MAINTENANCE | 2 | 2 | 10/4/2018 | 9/21/2019 |
