NY DOH Inspection Report

Brothers of Mercy Nursing & Rehabilitation Center

📍 10570 Bergtold Road, Clarence, NY 14031

Citations Summary

Feb 2022 – Jan 2026
11 Inspections Conducted
8
No citations found
73% of all inspections
3
Resulted in citations
27% of all inspections
16 Total Citations — state avg: 23
Issued across those 3 inspections
12Standard Health
4Life Safety Code
Severity of Citations
How serious were those 16 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period

Inspection Details

Surveys with Citations Only
January 16, 2026 Certification Survey 9 Health 17 LSC
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
Bowel/bladder Incontinence, Catheter, Uti
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
Infection Prevention & Control
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
License/comply W/ Fed/state/locl Law/prof Std
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤👤👤 Widespread Not yet corrected
Physical Environment
Standard Health Citation — quality of care
Level 0 👤 Scope Not yet corrected
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
Resident Rights/exercise Of Rights
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
Responsibilities Of Providers; Required Notif
Standard Health Citation — quality of care
Level 0 👤 Scope Not yet corrected
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Level 1 · Potential for minimal harm 👤👤👤 Pattern Not yet corrected
Life Safety Code Citations
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Egress Doors
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Elevators
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Exit Signage
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Fire Alarm System - Testing And Maintenance
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
General Requirements - Other
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
Hazardous Areas - Enclosure
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Illumination Of Means Of Egress
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Maintenance, Inspection & Testing - Doors
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
Portable Fire Extinguishers
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Portable Space Heaters
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
January 9, 2024 Certification/Complaint Survey 6 Health 7 LSC
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated March 1, 2024
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated March 1, 2024
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated March 1, 2024
Other Laws, Codes, Rules And Regulations.
Standard Health Citation — quality of care
Level 0 👤 Scope March 1, 2024
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Level 1 · Potential for minimal harm 👤👤👤 Pattern March 1, 2024
Treatment/svcs To Prevent/heal Pressure Ulcer
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated March 1, 2024
Life Safety Code Citations
Egress Doors
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern March 1, 2024
Fire Drills
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern March 1, 2024
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern March 1, 2024
Hazardous Areas - Enclosure
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern March 1, 2024
Illumination Of Means Of Egress
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern March 1, 2024
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern March 1, 2024
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern March 1, 2024
March 2, 2022 Certification/Complaint Survey 0 Health 3 LSC
▼
Life Safety Code Citations
Egress Doors
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern March 4, 2022
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern March 10, 2022
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤 Isolated March 31, 2022
Severity Scale Reference
Level 0 — No Harm Potential Level 2 — Minor Potential Harm Level 3 — Actual Harm Level 4 — Immediate Jeopardy

Complaints

Feb 2022 – Jan 2026
Below state average. This facility received 27.1 complaints per 100 beds vs. a statewide rate of 55.0. 0 citations resulted from those complaints (0.0 per 100 beds vs. 3.0 statewide).
Total Complaints
57
55,221 statewide
Per 100 Occupied Beds
27.1
55.0 state avg
On-Site Inspections
11
8,103 statewide
Citations Issued
0
0.0 per 100 beds · avg 3.0
Facility-Reported Incidents
84%
55% statewide
Citations by CategoryThis Facility
Administration0
Dietary Services0
Other Services0
Physical Environment0
Quality of Care3
Resident Rights0
Total3

Enforcement & Fines

Feb 2016 – Jan 2026
1 enforcement action totaling $6,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
August 18, 2020
$6,000
Stipulation & Order #NH-20-061 · Signed October 6, 2020
Reason: Multiple Deficiencies