Cycle 1
Health 2024-10-15 · Fire 2024-10-15
15 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Guilderland, NY
Our Lady Of Mercy Life Center
1-star overall rating with 1-star inspections with abuse icon flag with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2 Mercycare Lane, Guilderland, NY
(518) 464-8100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
152
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1993-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,792
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.60
Baseline 16.67% · Performance 19.76% · Measure score 3.60 · Achievement 3.60 · Improvement 0
Healthcare-associated infections
0
Baseline 4.90% · Performance 8.73% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 56.36% · Performance 67.96% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.51
Baseline 3.75 hours · Performance 3.79 hours · Measure score 2.51 · Achievement 2.51 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.58% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 220 · Observed rate 8.18% · Lower 95% interval 6.74% |
| Discharge to community | 50.54% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 215 · Observed rate 44.19% · Lower 95% interval 43.78% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 164 · Denominator 164 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 164 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 52 · Denominator 117 |
| Discharge mobility score | 38.46% |
50.94%
12.5 pts worse
|
Numerator 45 · Denominator 117 |
| Pressure ulcers or injuries, new or worsened | 3.05% |
2.29%
0.8 pts worse
|
Numerator 5 · Denominator 164 · Adjusted rate 3.4% |
| Healthcare-associated infections requiring hospitalization | 8.73% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 152 · Observed rate 9.87% · Lower 95% interval 6.31% |
| Staff COVID-19 vaccination coverage | 8.16% |
8.2%
About the same
|
Numerator 20 · Denominator 245 |
| Staff flu vaccination coverage | 41.35% |
42%
0.6 pts worse
|
Numerator 129 · Denominator 312 |
| Discharge function score | 41.88% |
56.45%
14.6 pts worse
|
Numerator 49 · Denominator 117 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 91 · Denominator 91 |
| Transfer of health information to patient | 96.88% |
96.28%
0.6 pts better
|
Numerator 31 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 34.48% |
25.2%
9.3 pts better
|
Numerator 30 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.7
0.5 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
91.2%
4.2 pts better
|
93.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 92.4% · Q3 97.5% · Q4 96.8% · 4Q avg 95.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
95.3%
3.1 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.0%
0.7 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.8% · Q3 2.5% · Q4 3.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
18.5%
18.2 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
6.1%
3.5 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.9% · Q3 0.0% · Q4 3.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
13.5%
5.7 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 18.0% · Q3 19.5% · Q4 22.0% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
14.8%
0.5 pts worse
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 12.6% · Q3 16.5% · Q4 16.7% · 4Q avg 15.3% · 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 | 15.7% |
15.1%
0.6 pts worse
|
16.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 25.2% · Q3 7.2% · Q4 11.2% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
15.5%
0.1 pts worse
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 16.3% · Q3 9.2% · Q4 15.5% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.6%
1.2 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.2% · Q3 1.2% · Q4 1.5% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.4%
0.3 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 4.3% · Q3 0.0% · Q4 1.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
20.8%
5.4 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 21.8% · Q3 34.2% · Q4 31.1% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.9%
0.7 pts better
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.9% · Q3 5.8% · Q4 8.4% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
76.7%
15.2 pts better
|
81.7%
10.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.9% · Q2 90.9% · Q3 91.9% · Q4 94.6% · 4Q avg 91.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
9.7%
1.6 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 7.7% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.2%
0.3 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 3.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.9% |
78.8%
11.1 pts better
|
79.7%
10.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
20.6%
1.6 pts worse
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 21.8% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-14 · Fire 2022-02-14
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-08-13 · Fire 2019-08-13
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-15
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-13
F · Potential for more than minimal harm
2024-10-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-15
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-12-06
E · Potential for more than minimal harm
2022-02-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-07
E · Potential for more than minimal harm
2019-08-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-10-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-15
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-10-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-10-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-10-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-10-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-09-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-11-11
D · Potential for more than minimal harm
2022-02-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-13
D · Potential for more than minimal harm
2022-02-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-04-13
D · Potential for more than minimal harm
2022-02-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-04-13
D · Potential for more than minimal harm
2022-02-14
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-04-13
D · Potential for more than minimal harm
2022-02-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-13
D · Potential for more than minimal harm
2022-02-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-04-13
D · Potential for more than minimal harm
2022-02-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-04-13
E · Potential for more than minimal harm
2019-08-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-09-30
C · Minimal harm
2019-08-13
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-09-30
Penalties and ownership
What sits behind the stars
Ownership
St Peters Health Partners
5% Or Greater Direct Ownership Interest · Organization
Trinity Health Corporation
5% Or Greater Indirect Ownership Interest · Organization
Bala, Guha
Corporate Director · Individual
Burke, Michael
Operational/Managerial Control · Individual
Farrell, Eric
Corporate Officer · Individual
Hanks, Steven
Corporate Director · Individual
Isacksen, Daniel
Corporate Director · Individual
Jimino, Kathleen
Corporate Officer · Individual
Lapczynski, Patricia
Corporate Director · Individual
Marshall, John
Corporate Officer · Individual
Mazzacco, Michelle
Operational/Managerial Control · Individual
Mccormick, Robert
Corporate Director · Individual
Meath, Michael
Corporate Director · Individual
Myers, Gina
Corporate Director · Individual
Pollard, Merriette
Corporate Director · Individual
Signor, Kristin
Operational/Managerial Control · Individual
Signor, Kristin
Corporate Officer · Individual
St Peters Health Partners
Operational/Managerial Control · Organization
Sullivan, Marguerite
Corporate Director · Individual
Sullivan-Smith, Sandra
Operational/Managerial Control · Individual
Sweet Zavaglia, Kerri
Corporate Director · Individual
Tofade, Oluwatoyin
Corporate Director · Individual
Trinity Health Corporation
Operational/Managerial Control · Organization
Wildridge, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
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The Grand Rehabilitation And Nrsg At Guilderland
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1-star overall rating with 1-star inspections with Special Focus status with $40,937 in total fines with 29 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
#2
Daughters Of Sarah Nursing Center
Albany, NY
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Teresian House Nursing Home Co Inc
Albany, NY
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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