Inspection Reports for
Brothers of Mercy Nursing & Rehabilitation Center
10570 Bergtold Road, Clarence, NY, 14031
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 1
Date: Jan 16, 2026
Visit Reason
The inspection was conducted to assess compliance with infection control and environmental safety standards in the nursing home, specifically focusing on the cleanliness and maintenance of shower rooms.
Findings
The facility failed to maintain a safe, clean, and homelike environment in two of six shower rooms, with issues including dirty floors, standing water, and unlabeled personal care items. Multiple observations and interviews confirmed inadequate cleaning practices and potential infection control risks.
Deficiencies (1)
F 0584: The facility did not provide a safe, clean, and homelike environment in the 3 East and 4 West shower rooms due to dirty floors, standing water, and unlabeled personal care items. These conditions posed a potential risk for infection and discomfort to residents.
Report Facts
Residents affected: 1
Shower rooms inspected: 6
Shower rooms with deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #15 | Interviewed regarding cleaning responsibilities and observations of brown substance in shower room | |
| Certified Nurse Aide #16 | Interviewed about importance of shower room cleanliness | |
| Certified Nurse Aide #3 | Observed and cleaned brown substance believed to be feces in shower room | |
| Certified Nurse Aide #7 | Reported flooding and cleaning responsibilities in shower room | |
| Licensed Practical Nurse #1 | Reported shower stall unsanitary conditions and unlabeled personal care items | |
| Housekeeping/Laundry Supervisor | Stated housekeeping responsibilities and condition of shower rooms | |
| Housekeeper #1 | Reported cleaning schedule and observations of shower room condition | |
| Director of Environmental Services | Stated expectations for cleaning and maintenance of shower rooms |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 9, 2024
Visit Reason
The inspection was a standard routine survey conducted to assess compliance with regulatory requirements in a nursing home facility.
Findings
The facility was found deficient in maintaining a clean and homelike environment due to dirty wall heaters, failure to provide necessary supervision and assistance with eating for a resident, inadequate pressure ulcer care for another resident, insufficient fall prevention measures for a resident with frequent falls, and improper storage of controlled medications.
Deficiencies (5)
F 0584: The facility did not provide housekeeping and maintenance services necessary to maintain a clean and comfortable environment, with multiple wall heaters observed with debris such as dust, dried leaves, and other items under plexiglass covers.
F 0677: Resident #118 was not provided continuous supervision or touching assistance with eating as planned, resulting in unsafe eating conditions and lack of proper meal assistance.
F 0686: Resident #142 developed an unstageable pressure ulcer with incomplete wound assessments and failure to implement wound consultant recommendations, including lack of proper turning and positioning and absence of required wound care orders.
F 0689: Resident #8 experienced over 60 falls since admission, and the facility failed to implement effective interventions to prevent falls despite known risks and multiple incidents.
F 0761: Controlled substances (Lorazepam) were stored in a locked box inside a refrigerator that was not permanently affixed, resulting in unsecured medication storage.
Report Facts
Falls: 100
Falls: 66
Medication volume: 28.25
Medication volume: 30
Medication volume: 30
Pressure ulcer size: 5
Pressure ulcer size: 7
Pressure ulcer size: 7.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | 3 East Unit Manager | Observed and commented on dirty heating registers and supervision needs for Resident #118. |
| Director of Plant Operations | Stated wall heaters are cleaned as needed with vacuum attachments and no cleaning schedule exists. | |
| Housekeeping Director | Expected staff to report dirty heating registers and stated maintenance responsibility for cleaning. | |
| Certified Nursing Assistant #8 | Observed debris on wall heaters and believed maintenance responsible for cleaning. | |
| Unit Manager Licensed Practical Nurse #6 | Believed maintenance responsible for cleaning wall heaters. | |
| Dietary Technician #1 | Documented Resident #118's meal intake and variable intake requiring encouragement. | |
| Occupational Therapist #2 | Provided assessment of Resident #118's feeding assistance needs. | |
| Registered Nurse #5 | Nurse Manager | Reviewed wound consultant recommendations and care plan for Resident #142. |
| Licensed Practical Nurse #3 | Provided wound care treatment for Resident #142. | |
| Director of Nursing | Discussed expectations for wound care and fall prevention interventions. | |
| Registered Nurse Manager #2 | Reviewed Resident #8's fall history and interventions. | |
| Registered Nurse Supervisor #3 | Discussed Resident #8's frequent falls and need for supervision. | |
| Occupational Therapist Registered #1 | Participated in fall committee meetings and assessed Resident #8's equipment and needs. | |
| Licensed Practical Nurse (LPN) #7 | Observed medication storage and handling of controlled substances. | |
| Unit Manager Registered Nurse (RN) #6 | Commented on medication storage requirements for controlled substances. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Jan 9, 2024
Visit Reason
Multiple quality of care and life safety deficiencies identified, all corrected by March 1, 2024.
Findings
Multiple quality of care and life safety deficiencies identified, all corrected by March 1, 2024.
Deficiencies (13)
ADL care provided for dependent residents
Free of accident hazards/supervision/devices
Label/store drugs and biologicals
Other laws, codes, rules and regulations
Safe/clean/comfortable/homelike environment
Treatment/svcs to prevent/heal pressure ulcer
Egress doors
Fire drills
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Illumination of means of egress
Means of egress - general
Sprinkler system - maintenance and testing
Inspection Report
Deficiencies: 0
Date: Mar 2, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Brothers of Mercy Nursing & Rehabilitation Center following a survey completed on March 2, 2022.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Mar 2, 2022
Visit Reason
Life safety code deficiencies related to egress doors, means of egress, and sprinkler system installation, all corrected by March 31, 2022.
Findings
Life safety code deficiencies related to egress doors, means of egress, and sprinkler system installation, all corrected by March 31, 2022.
Deficiencies (3)
Egress doors
Means of egress - general
Sprinkler system - installation
Inspection Report
Routine
Deficiencies: 1
Date: Jul 15, 2019
Visit Reason
The inspection was a standard survey conducted to assess compliance with regulations regarding the care of residents, specifically focusing on the appropriate use and administration of feeding tubes.
Findings
The facility failed to ensure that a resident with a gastrostomy feeding tube received the correct tube feed formula as ordered by the physician. Nursing staff administered Jevity 1.5 instead of the ordered Jevity 1.2 formula, and the facility did not have the correct formula on hand.
Deficiencies (1)
F 0693: The facility did not provide the correct tube feed formula as ordered for a resident with a gastrostomy tube. Nursing staff administered Jevity 1.5 instead of Jevity 1.2, and the facility lacked the correct formula on hand.
Report Facts
Deficiencies cited: 1
Cartons of Jevity 1.2 received: 56
Tube feed volume: 237
Water flush volume: 150
Resident weight goal range: 128 to 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered incorrect tube feed formula |
| ADON RN #1 | Assistant Director of Nursing, Registered Nurse | Reviewed orders and confirmed incorrect feed administration |
| RD #1 | Registered Dietitian | Notified of incorrect feed and contacted supplier |
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