Provider Name: BROTHERS OF MERCY NURSING & REHABILITATION CENTER
Address: 10570 BERGTOLD ROAD, CLARENCE, NY 14031
Phone: (716) 759-6985
County: Erie (240)
Ownership Type: Non profit - Corporation
Certified Beds: 240
Average Residents Per Day: 203. ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: BROTHERS OF MERCY NURSING HOME COMPANY INC
First Approved Date: January 1, 1967
Affiliated Entity: ()
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: None
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 5 ()
QM Rating: 4 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 3 ()
Staffing Rating: 4 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.20384, LPN Staff Hours Per Day: 1.3716, RN Staff Hours Per Day: 0.6347, Licensed Staff Hours Per Day: 2.0063
Total Nurse Staff Hours Per Day, per resident: 4.21023
Weekend Nurse Staff Hours: 3.59540, Weekend RN Staff Hours: 0.3145
PT Staff Hours Per Day, per resident: 0.1490
Nurse Staff Turnover: 43.3, Nurse Turnover Note:
RN Turnover: 29.0, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.2329, Case Mix LPN Hours Per Day: 0.8123, Case Mix RN Hours Per Day: 0.4427
Adjusted Nurse Aide Hours Per Day, per resident: 2.01067, Adjusted LPN Hours Per Day: 1.2461, Adjusted RN Hours Per Day: 0.5401
Total Adjusted Nurse Hours Per Day, per resident: 3.80463
Adjusted Weekend Nurse Hours Per Day, per resident: 3.24902
Health Survey Dates and Scores: Cycle 1: 2024-01-09 (Score: 16), Cycle 2: 2022-03-02 (Score: 0), Cycle 3: 2019-07-15 (Score: 4)
Total Weighted Health Score: 8.667
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 0, Total Fines in Dollars: 0.00, Payment Denials Number: 0, Total Penalties Number: 0
Location and GPS: 10570 BERGTOLD ROAD,CLARENCE,NY,14031 (42.9661, -78.596)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Health, Deficiency: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-09-09
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Fire Safety, Tag: 0222, Version: New
Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Fire Safety, Tag: 0281, Version: New
Description: Install proper backup exit lighting.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Fire Safety, Tag: 0712, Version: New
Description: Have simulated fire drills held at unexpected times.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-01
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-03-10
Type: Fire Safety, Tag: 0222, Version: New
Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-03-04
Type: Fire Safety, Tag: 0351, Version: New
Description: Install an approved automatic sprinkler system.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-03-31
Type: Fire Safety, Tag: 0223, Version: New
Description: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-09-09
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-09-09
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-09-09
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-09-09