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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.80
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.61
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
5.20
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
980
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.42
Composite VBP score used to determine payment impact.
Payment multiplier
1.0165
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.09
Baseline 62.66% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 4.74
Adjusted total nurse staffing
7.19
Baseline 4.86 hours · Performance 5.12 hours · Measure score 7.19 · Achievement 7.19 · Improvement 2.39
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 15.2% |
8.2%
7 pts better
|
Numerator 26 · Denominator 171 |
| Staff flu vaccination coverage | 48.79% |
42%
6.8 pts better
|
Numerator 101 · Denominator 207 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
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 · Q1 100.0% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 · 4Q avg 98.8% |
| 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 · Q1 1.2% · Q2 3.8% · Q3 3.6% · Q4 4.9% · 4Q avg 3.3% · Used in QM five-star |
| 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 · Q1 1.2% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.6% |
| 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 · Q1 8.5% · Q2 7.1% · Q3 2.8% · Q4 1.4% · 4Q avg 4.9% |
| 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 · Q1 13.9% · Q2 14.3% · Q3 13.9% · Q4 16.4% · 4Q avg 14.6% |
| 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 · Q1 7.2% · Q2 11.6% · Q3 11.3% · Q4 13.4% · 4Q avg 10.9% · 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 | 12.6% |
15.1%
2.5 pts better
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 0.0% · Q3 20.4% · Q4 11.7% · 4Q avg 12.6% · Used in QM five-star |
| 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 · Q1 20.6% · Q2 9.7% · Q3 15.9% · Q4 13.4% · 4Q avg 14.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 2.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| 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 · Q1 1.2% · Q2 2.5% · Q3 1.2% · Q4 1.2% · 4Q avg 1.5% · Used in QM five-star |
| 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 · Q1 28.5% · Q2 33.2% · Q3 30.6% · Q4 28.7% · 4Q avg 30.2% |
| 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 · Q1 7.4% · Q2 11.1% · Q3 8.2% · Q4 9.0% · 4Q avg 8.9% · Used in QM five-star |
| 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 · 4Q avg 88.9% |
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
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#3
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