Cycle 1
Health 2024-01-09 · Fire 2024-01-09
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Clarence, NY
Brothers Of Mercy Nursing & Rehabilitation Center
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
10570 Bergtold Road, Clarence, NY
(716) 759-6985
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
240
Certified beds
Average residents
201
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.15
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.28
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,328
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9933
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.43
Baseline 21.30% · Performance 19.84% · Measure score 3.43 · Achievement 3.43 · Improvement 2.92
Healthcare-associated infections
3.68
Baseline 6.63% · Performance 6.73% · Measure score 3.68 · Achievement 3.68 · Improvement 0
Total nurse turnover
4.18
Baseline 39.32% · Performance 46.59% · Measure score 4.18 · Achievement 4.18 · Improvement 0
Adjusted total nurse staffing
4.86
Baseline 4.19 hours · Performance 4.46 hours · Measure score 4.86 · Achievement 4.86 · Improvement 1.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.14% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 209 · Observed rate 8.61% · Lower 95% interval 7.15% |
| Discharge to community | 51.05% |
50.57%
0.5 pts better
|
No Different than the National Rate · Eligible stays 209 · Observed rate 47.37% · Lower 95% interval 43.12% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.34% |
95.27%
1.1 pts better
|
Numerator 158 · Denominator 164 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 164 |
| Discharge self-care score | 40.29% |
53.69%
13.4 pts worse
|
Numerator 56 · Denominator 139 |
| Discharge mobility score | 57.55% |
50.94%
6.6 pts better
|
Numerator 80 · Denominator 139 |
| Pressure ulcers or injuries, new or worsened | 1.22% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 164 · Adjusted rate 1.27% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 5.43% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 337 |
| Staff flu vaccination coverage | 54.36% |
42%
12.4 pts better
|
Numerator 318 · Denominator 585 |
| Discharge function score | 48.92% |
56.45%
7.5 pts worse
|
Numerator 68 · Denominator 139 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 97.37% |
96.28%
1.1 pts better
|
Numerator 111 · Denominator 114 |
| Resident COVID-19 vaccinations up to date | 30.23% |
25.2%
5 pts better
|
Numerator 26 · Denominator 86 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.2 |
1.7
1.5 pts better
|
1.9
1.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.3
1.3 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
91.2%
7.8 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.4% · Q3 99.3% · Q4 98.1% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
95.3%
2.9 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.0%
1 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.9% · Q3 4.7% · Q4 4.5% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
18.5%
12.9 pts better
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.2% · Q3 5.5% · Q4 4.6% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
6.1%
0.2 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 7.7% · Q3 5.2% · Q4 5.3% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.3% |
13.5%
3.8 pts worse
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 17.3% · Q3 17.9% · Q4 12.3% · 4Q avg 17.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
14.8%
2.9 pts worse
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 17.4% · Q3 17.3% · Q4 16.3% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.7% |
15.1%
12.6 pts worse
|
16.3%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 22.6% · Q3 34.7% · Q4 33.1% · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.4% |
15.5%
0.9 pts worse
|
14.9%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 11.4% · Q3 16.3% · Q4 22.8% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.6%
0.2 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.6% · Q3 0.5% · Q4 1.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.4%
0.3 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.9% · Q3 1.4% · Q4 0.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.4% |
20.8%
13.6 pts worse
|
19.8%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.7% · Q2 38.9% · Q3 28.1% · Q4 28.1% · 4Q avg 34.4% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.9%
1.9 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.0% · Q3 4.6% · Q4 6.6% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
76.7%
15.6 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 89.1% · Q3 94.7% · Q4 95.6% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.3% |
9.7%
7.4 pts better
|
12.0%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.3% · Observed 2.0% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.2%
1.1 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.3% |
78.8%
11.5 pts better
|
79.7%
10.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
20.6%
0.6 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 17.2% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-02 · Fire 2022-03-02
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-07-15 · Fire 2019-07-15
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-01-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-09
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-01
E · Potential for more than minimal harm
2022-03-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-03-02
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-03-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-03-31
E · Potential for more than minimal harm
2019-07-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-09-09
D · Potential for more than minimal harm
2019-07-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-09-09
D · Potential for more than minimal harm
2019-07-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-09-09
D · Potential for more than minimal harm
2019-07-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-09-09
Inspection history
Recent health citations
B · Minimal harm
2026-01-16
F584 · Resident Rights Deficiencies
Health
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.
Not marked corrected
D · Potential for more than minimal harm
2024-01-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-09
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-03-01
B · Minimal harm
2024-01-09
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-01
D · Potential for more than minimal harm
2019-07-15
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2019-09-09
Penalties and ownership
What sits behind the stars
Ownership
Dillsworth, Teresa
Operational/Managerial Control · Individual
Dillsworth, Teresa
Corporate Officer · Individual
Elmer, Peter
Operational/Managerial Control · Individual
Elmer, Peter
Corporate Officer · Individual
Gugino, Stacey
Operational/Managerial Control · Individual
Ingham, Jamie
Operational/Managerial Control · Individual
Nowicki, Jennifer
Operational/Managerial Control · Individual
Thomas, Kenneth
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Harris Hill Nursing Facility, L L C
Williamsville, NY
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Greenfield Health & Rehab Center
Lancaster, NY
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Canterbury Woods
Williamsville, NY
2-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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