MCAULEY RESIDENCE

Nursing Home Inspector

1503 MILITARY ROAD
KENMORE, NY 14217
Erie County
Phone: 716-447-6600
Provider Number: 335433
Last Inspection: 10/20/2016

About the Nursing Home

Number of Beds: 160
Number of Residents: 131
Beds Available: 29
Percent Occupancy: 82%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: Non profit - Church related
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

12

Facility
18

County
14

NY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

12

2016
18

2015
19

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

10/20/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 12/9/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 12/9/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 12/9/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 12/9/2016
 

12/15/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 2/8/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 2/8/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 2/8/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 2/8/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 2/8/2016
 
Failed To: Operate and provide services according to Federal, State, and local laws and professional standards. Isolated : Minimal 3 2/8/2016
 

12/9/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 1/31/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 1/31/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 1/31/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 1/31/2015
 
Failed To: Provide or obtain dental services for each resident. Isolated : Minimal 3 1/31/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 1/31/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

7/2/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 7/2/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 7/2/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NY State Avg
Number of Residents 131 145.81 167.28
Registered Nurses 1.55 0.79 0.74
Licensed Practical / Vocational Nurses 0.81 0.98 0.84
Certified Nursing Assistants 2.56 2.43 2.30
Total Staff Hours 4.92 4.20 3.88

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NY State Avg%
of high risk long-stay residents with pressure ulcers 8 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 96 92 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 94 96
of long-stay residents experiencing one or more falls with major injury 1 2 2
of long-stay residents who have depressive symptoms 4 7 8
of long-stay residents who lose too much weight 3 5 6
of long-stay residents who received an antianxiety or hypnotic medication 15 15 15
of long-stay residents who received an antipsychotic medication 8 13 13
of long-stay residents who self-report moderate to severe pain 1 4 3
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 21 21 16
of long-stay residents whose need for help with daily activities has increased 7 16 13
of long-stay residents with a catheter inserted and left in their bladder 1 1 1
of long-stay residents with a urinary tract infection 2 2 3
of low risk long-stay residents who lose control of their bowels or bladder 80 57 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 96 80 81
of short-stay residents who had an outpatient emergency department visit 11 10 9
of short-stay residents who made improvements in function 48 68 68
of short-stay residents who newly received an antipsychotic medication 2 1 1
of short-stay residents who self-report moderate to severe pain 18 10 9
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 92 82 82
of short-stay residents who were rehospitalized after a nursing home admission 15 19 21
of short-stay residents who were successfully discharged to the community 77 55 48
of short-stay residents with pressure ulcers that are new or worsened 2 1 0