Cycle 1
Health 2025-07-24 · Fire 2025-07-24
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lackawanna, NY
Mercy Hospital Skilled Nursing Facility
5-star overall rating with 4-star inspections with 3 recent health deficiencies
55 Melroy Avenue, Lackawanna, NY
(716) 819-5300
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
84
Certified beds
Average residents
83
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1970-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing
LPN hours / resident day
1.21
Licensed practical nurse staffing
Aide hours / resident day
2.80
Nurse aide staffing
Weekend hours
4.02
Weekend nurse staffing
RN turnover
29%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.2%
8.5 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
95.3%
3.5 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.0%
0.3 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
18.5%
17.9 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.9% |
6.1%
1.2 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
13.5%
1.1 pts worse
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
14.8%
3.9 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.6% |
15.1%
2.5 pts better
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.9% |
15.5%
0.6 pts better
|
14.9%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.6%
0.1 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.4%
0.1 pts worse
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
20.8%
9.4 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.9% |
6.9%
2 pts worse
|
5.1%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
76.7%
12.2 pts better
|
81.7%
7.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-02 · Fire 2024-02-02
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-07-29 · Fire 2022-07-29
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-02
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 2024-03-11
E · Potential for more than minimal harm
2024-02-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-11
E · Potential for more than minimal harm
2022-07-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-16
E · Potential for more than minimal harm
2022-07-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-06
E · Potential for more than minimal harm
2022-07-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-06
E · Potential for more than minimal harm
2022-07-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-06
E · Potential for more than minimal harm
2022-07-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-09-06
E · Potential for more than minimal harm
2022-07-29
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-07-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-07-29
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-09-06
E · Potential for more than minimal harm
2022-07-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-09-06
D · Potential for more than minimal harm
2022-07-29
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-09-06
D · Potential for more than minimal harm
2022-07-29
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-08-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-24
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-24
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-08
D · Potential for more than minimal harm
2022-07-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-08-29
Penalties and ownership
What sits behind the stars
Ownership
Agnello, Alexis
Corporate Officer · Individual
Edwards, Russell
Operational/Managerial Control · Individual
Edwards, Russell
Corporate Officer · Individual
Garvey, James
Corporate Officer · Individual
Gleason, Thomas
Operational/Managerial Control · Individual
Gleason, Thomas
Corporate Officer · Individual
Macholz, David
Corporate Officer · Individual
Markiewicz, Joyce
Corporate Officer · Individual
O Connor, Patricia
Operational/Managerial Control · Individual
O Connor, Patricia
Corporate Director · Individual
Osborne, Clayton
Operational/Managerial Control · Individual
Osborne, Clayton
Corporate Director · Individual
Sette-Camara, Leonardo
Corporate Director · Individual
Snyder, Brian
Operational/Managerial Control · Individual
Zapfel, Robert
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Buffalo, NY
2-star overall rating with 2-star inspections with $10,489 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Seneca Health Care Center
West Seneca, NY
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Garden Gate Health Care Facility
Cheektowaga, NY
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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