Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brothers Of Mercy Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Carbon monoxide detectors were not maintained and tested in accordance with applicable requirements, affecting all four resident-use floors. Fuel-burning appliances were located on the first and fourth floors, and single-station battery-operated CO detectors were observed in several locations. The facility’s audit showed only seven weeks of entries for eight units, while staff interviews confirmed inconsistent testing and missing documentation, despite the Administrator stating the detectors were expected to be tested per manufacturer guidelines.
A resident was left waiting nearly an hour for toileting help, then had to transfer themselves to the toilet and became incontinent after no one responded. In a separate incident, two cognitively intact residents reported that CNAs entered their room without knocking, held a personal conversation, and one CNA made an undignified, vulgar remark after being asked to leave. The DON and Administrator acknowledged the comment was not an acceptable way to speak to a resident.
Delayed Reporting of Alleged Verbal Abuse: An allegation of verbal/mental abuse involving two cognitively intact residents was not reported to the state within the required 2-hour timeframe. A resident reported that an aide made a rude, vulgar comment after the resident asked staff to leave the room, but the DON and Administrator delayed reporting while the facility investigated and initially viewed the issue as a dignity concern.
Delayed Toileting and Incontinent Care: Two residents did not receive toileting and incontinent care as planned. One resident, dependent for toilet transfer and hygiene, waited nearly an hour after a call light went unanswered and then had to transfer to the toilet alone, resulting in incontinence. Another resident, who was severely cognitively impaired and dependent for toileting hygiene, was not checked for incontinence per the care plan, and a CNA stated no incontinence care had been provided since the start of the shift until later that day.
Foley Catheter Lacked Indication and Proper Care A resident admitted with a Foley catheter had no documented clinical justification for continued use and no documented voiding trial, despite baseline incontinence and a hospital note stating the catheter should be removed once the resident was more ambulatory. Staff observations showed the drainage bag and tubing repeatedly on the floor, the catheter not secured to the resident, and the bag disconnected and then reconnected before being placed back on the floor. Interviews with the DON, ADON/IP, LPN, CNA, and NP confirmed the lack of clear documentation for the catheter and that the bag should not touch the floor and should be secured properly.
Infection prevention and control was not maintained for two residents. One resident had unstageable pressure ulcers with drainage, but Enhanced Barrier Precautions were not in place when wound care was provided and staff did not wear gowns. Another resident was already on EBP for a chronic wound, yet CNAs provided incontinent care without gowns despite posted signage and PPE being available. The DON and unit manager stated gowns were expected for high-contact care.
The facility failed to maintain two shower rooms in a safe, clean, and homelike condition, despite policies requiring daily cleaning and infection control measures. Surveyors observed a brown substance on a shower stall floor on one unit over two days before it was cleaned, and staff gave inconsistent accounts of who was responsible for cleaning and how often it occurred. On another unit, surveyors repeatedly found standing water, hair, and a bandage blocking a shower drain, along with multiple opened, unlabeled personal care products stored on shelves in both stalls. A resident reported having to shower in lukewarm water while sitting in standing water, and staff, including a CNA, an LPN, and housekeeping leadership, acknowledged that the shower stalls appeared dirty, unsanitary, and not homelike, with soap scum, hair, bandages, and what appeared to be feces present.
Carbon Monoxide Detector Testing and Maintenance
Penalty
Summary
The facility was found not to be in compliance with Section 915 of the 2020 Fire Code of New York State because carbon monoxide detectors were not being maintained and tested in accordance with applicable requirements. The deficiency affected all four resident-use floors, and the report noted that fuel-burning appliances were located on the first and fourth floors. During the building tour, single-station battery-operated carbon monoxide detectors were observed at several locations on the first and fourth floors, and they were mostly Brand A and Brand B units. The facility’s undated Directive and Procedure titled Testing of Carbon Monoxide Detectors stated that detectors would be manually tested weekly according to manufacturer specifications and kept free of dust and debris. Review of the Weekly Carbon Monoxide Detector Audit showed eight units with entries for seven weeks between 11/18/2025 and 01/06/2026. During interviews, the Maintenance Director stated they had personally performed weekly carbon monoxide detector checks since starting at the facility in November 2025, but could not locate documentation of checks before that time. Maintenance Technician #1 stated they had not personally performed any carbon monoxide detector checks, and Maintenance Technician #2 stated they had tested the carbon monoxide detectors in the Maintenance Shop a few times in Fall 2025 but did not document it. The Administrator stated they expected the carbon monoxide detectors in the building to be tested per manufacturer guidelines.
Failure to Maintain Resident Dignity and Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity and that care was provided in a manner that maintained their quality of life. The deficiency involved three residents. Two cognitively intact residents, both able to make their needs known, reported that staff entered their room without knocking and began a personal conversation while one resident’s roommate was being assisted. When the residents asked the staff to continue the conversation outside the room, one CNA responded with a rude and undignified remark that included vulgar slang about providing care. Both residents described the comment as rude, uncalled for, and inappropriate, and one stated the comment was unacceptable in their home. The incident was investigated by the facility, and statements from the residents and staff reflected that staff were in the room having a personal conversation and that the exchange was inappropriate. One CNA denied using profanity, while another staff member stated the comment should not have been made and that it was disrespectful to enter a resident’s room and have a personal conversation there. The DON and Administrator both stated that staff were expected to treat residents with dignity and respect and that the comment made in the residents’ presence was not an acceptable way to speak to a resident. The facility also failed to provide timely toileting assistance to another cognitively intact resident who was dependent for toilet transfers and toileting hygiene. The resident reported that their call light went unanswered for almost an hour, after which they wheeled themselves to the nurses’ station to ask for help using the bathroom. The resident stated no one came, so they transferred themselves to the toilet even though they knew they were not supposed to, and they had an incontinence episode that upset them. The call light log showed the resident’s call light remained on for nearly an hour, and staff interviews confirmed the resident reported being made to wait and becoming incontinent after trying to toilet themselves.
Delayed Reporting of Alleged Verbal Abuse
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse were reported immediately, and no later than two hours after the allegation was made, to the State Survey Agency for two residents reviewed for abuse. The deficiency involved an allegation of verbal/mental abuse that was not reported to the New York State Department of Health within the required timeframe. The facility policy stated that all alleged violations involving abuse, neglect, exploitation, or mistreatment were to be reported immediately, but not later than two hours after the allegation was made. Resident #32 had diagnoses including congestive heart failure, anxiety disorder, and chronic obstructive pulmonary disease. The resident was documented as cognitively intact, able to understand and be understood by others, and independent with decision making with capacity for health care decisions. Resident #59 had diagnoses including parkinsonism, depression, and anxiety, and was also documented as cognitively intact, able to understand and be understood by others, with modified independence in decision making and capacity for health care decisions. During a resident council meeting, Resident #32 reported that while Certified Nurse Aide #2 was assisting Resident #59, Certified Nurse Aide #1 and Certified Nurse Aide #3 entered the room and began a personal conversation. Resident #32 stated that when they asked the staff to leave and continue their conversation outside, Certified Nurse Aide #1 responded with a vulgar remark about wiping residents and taking care of them, which Resident #32 described as rude and unacceptable. The incident was reported to the ADON and DON immediately by the surveyor, but the facility incident report showed the allegation was not reported to the Department of Health until two days later. The DON stated the allegation was initially considered a dignity concern and was not reported sooner because the investigation was still being conducted, while the Administrator stated the report was delayed because the facility was still investigating the allegation.
Delayed Toileting and Incontinent Care
Penalty
Summary
The facility did not ensure that residents who were unable to perform activities of daily living received the necessary toileting and incontinent care to maintain personal hygiene. The deficiency involved two residents who were dependent on staff for toileting-related care and whose care plans and Kardexes directed staff to provide timely assistance, including prompt response to call lights, toileting assistance as needed, and regular incontinence checks. One resident had diagnoses including CHF, CVA, and type 2 diabetes mellitus, and was documented as dependent on staff for toilet transfer and toileting hygiene. The resident reported that a call light went unanswered for almost an hour over the weekend, after which the resident wheeled to the nurses’ station, asked for help to use the bathroom, and still did not receive assistance. The resident stated they transferred themselves to the toilet, did not make it in time, and soiled themselves. The call light log documented the room call light was on for nearly an hour, and staff interviews confirmed the resident reported the delay and that it was not reasonable to wait that long for toileting assistance. The second resident had diagnoses including a right femur fracture, dementia, and major depressive disorder, and was documented as severely cognitively impaired and dependent for toileting hygiene. The resident’s care plan and Kardex directed staff to check for incontinence every two hours and assist with toileting as needed. During observation, the resident remained in a wheelchair near the nurses’ station for several hours and was later found in bed fully dressed; a CNA stated they had not checked the resident for incontinence since arriving because it was hectic and that this was the first incontinent care provided that day. Later that day, the resident was observed incontinent of stool and received fecal incontinence care at that time.
Foley Catheter Lacked Documented Indication and Was Improperly Maintained
Penalty
Summary
The facility did not ensure that a resident admitted with an indwelling Foley catheter was assessed for removal as soon as possible unless the resident’s clinical condition required continued catheterization. Resident #168 had diagnoses including a right femur fracture, dementia, and major depressive disorder, and was documented as severely cognitively impaired, dependent for toileting hygiene, and incontinent at baseline. The admission data collection form documented the resident’s usual bladder pattern as incontinent with use of a pad/brief/liner, with no history of urinary retention or urinary tract infections, yet an indwelling catheter was present with no reason documented for its use. The resident’s care plan and Kardex included Foley catheter care and positioning of the drainage bag and tubing below the bladder, but the record lacked documented medical justification for the catheter. The hospital discharge summary stated the Foley catheter was to be removed once the resident was more ambulatory. A social services note documented that the DON planned to ask for a void trial, but there was no documentation that a voiding trial was ordered or completed. Medical visit notes reviewed over several dates also lacked evidence of the presence of an indwelling catheter and a valid clinical indication to support its continued use. Observations showed the catheter bag and tubing were repeatedly on the floor and not secured. On one observation, the drainage bag spigot and bottom of the bag were resting on the floor with no privacy bag. On another, the bag was touching the floor, the catheter appeared to be pulling, and it was not secured to the resident’s leg; strong urine odor and dark urine were noted. During another observation, the catheter had disconnected from the drainage bag, was taut, and the drainage bag was again placed directly on the floor. Staff interviews confirmed that the bag should not touch the floor, should be placed in a privacy bag, and should be secured to the resident’s thigh, while the DON, ADON/Infection Preventionist, LPN, and NP all acknowledged the lack of clear documentation for the catheter’s indication and the importance of timely removal.
Infection Prevention and Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an infection prevention and control program for two residents. One resident had dementia, protein calorie malnutrition, hypothyroidism, and severe cognitive impairment, and developed unstageable pressure ulcers to both trochanters with eschar, erythema, and drainage. The wound consultant documented the ulcers as new and acquired on 01/02/2026, with light serous drainage noted on 01/06/2026 and again on 01/13/2026. Although the care plan later included Enhanced Barrier Precautions, the record showed they were not implemented until 01/15/2026, and there was no evidence of the precautions on the resident’s door or in the Kardex during earlier observations. During wound care for this resident, an LPN and a CNA entered the room, performed hand hygiene, and applied gloves, but no Enhanced Barrier Precaution sign was posted and no gowns were present. The old dressing from the right hip was removed and discarded, and the wound was observed with eschar, moist edges, and reddened peri-wound skin. The left hip dressing was also removed and was observed to have a moderate amount of drainage covering most of the dressing, with the wound bed covered by eschar and yellow, moist edges. The LPN stated the drainage appeared to include old Medi-honey mixed with yellow/green pus-colored drainage. The staff used gloves and masks but did not wear gowns. A second resident had dementia, chronic kidney disease, and adult failure to thrive, was dependent on staff for toileting, and had a chronic wound with a history of heel pressure injuries. The care plan and Kardex documented Enhanced Barrier Precautions with gown and glove use during high-contact care, and a nursing progress note stated the precautions were to remain in place due to the chronic wound. During observation, two CNAs provided incontinent care without wearing gowns even though an Enhanced Barrier Precaution sign was posted on the door and PPE was available outside the room. The CNAs stated they forgot to don PPE or believed the precautions applied to the roommate, and the unit manager and DON stated gowns were expected for this type of high-contact care.
Unclean Shower Rooms and Unlabeled Personal Care Items in Resident Bathing Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in two of six shower rooms (3 East and 4 West), contrary to its own housekeeping and infection control procedures. Facility policies required shower rooms and chairs to be cleaned daily, floors to be free of dirt and debris, and walls and doors to be disinfected or spot-cleaned if visibly soiled, as part of an infection control program intended to provide a safe, sanitary environment. Despite these procedures, surveyors observed a brown substance on the floor of the first shower stall in the 3 East shower room on one day, which remained present the following morning before it was later removed. Staff interviews on 3 East showed uncertainty and inconsistency regarding responsibility and frequency for cleaning the shower room. One CNA stated that if the brown substance was a bodily fluid, CNAs were responsible for cleaning it, but they had not provided showers on the days in question and were unsure how often the shower room was cleaned, though they believed it should be disinfected between each resident. Another CNA emphasized the importance of keeping the shower clean between residents and described the shower room as part of the residents’ home. A third CNA reported seeing the brown substance on the 3 East shower stall floors, believed it to be human feces, and cleaned and disinfected the area immediately, noting that shower rooms are “hot spots” for germs and that some residents have open wounds. In the 4 West shower room, repeated observations over several days showed multiple opened, unlabeled personal care items (shaving creams, moisturizing cream, skin guard, shampoo, body wash, antifungal powders) stored on shelves in both shower stalls, and a second stall with standing water, hair, and a bandage covering the drain. During one observation, a resident receiving a shower in the second stall reported that the water was not draining properly and described sitting on a stool in lukewarm water with approximately a half inch of standing water on the floor, stating it was not like showering at home. A CNA reported that the floor did not look clean prior to the shower, with hair and a bandage blocking the drain, and stated that resident care items should be labeled and not used for other residents. An LPN described the stall as not clean and sanitary, citing soap scum, hair over the drain, a gauze bandage, and what appeared to be feces on the floor, and noted that unlabeled personal care items should not be stored in the shower room. The housekeeping/laundry supervisor and a housekeeper both acknowledged that the shower floor was dirty, needed scrubbing, had not been mopped since the prior week, and that the condition was not homelike, despite expectations that shower floors and walls be cleaned daily.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 142 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clarence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harris Hill Nursing Facility, L L C | 4.7 mi | ★★★★★ | 9 | 0 |
| Greenfield Health & Rehab Center | 5.2 mi | ★★★★★ | 1 | 0 |
| Canterbury Woods | 6.7 mi | ★★★★★ | 0 | 0 |
| Elderwood At Lancaster | 6.7 mi | ★★★★★ | 2 | 0 |
| Elderwood At Williamsville | 7.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.