Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Our Lady Of Mercy Life Center during CMS and state inspections, most recent first.
The facility failed to ensure residents were aware of and could access the grievance process, as six residents reported being unaware of how to file grievances. Observations showed no visible grievance forms or signage, and staff interviews revealed inconsistencies in form availability and accessibility. The grievance process was not effectively communicated, leading to a deficiency in honoring residents' rights to voice grievances.
Two residents in the facility expressed dissatisfaction with the frequency of their bathing routines, which were not aligned with their preferences. One resident, with multiple sclerosis, reported inadequate bathing leading to skin issues, while another resident, cognitively intact, desired more frequent showers than provided. Despite staff efforts, the facility failed to consistently honor these residents' choices, resulting in a deficiency in promoting resident self-determination.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and missed care for residents. Observations and interviews revealed that staffing levels were below the required minimums, leading to long wait times for assistance and unmet care needs. Residents and staff reported significant challenges due to understaffing, particularly on weekends and night shifts.
The facility failed to properly label and store medications, with issues such as missing expiration dates on insulin pens, unlocked medication carts, and personal items stored with medical supplies. A narcotic lock box had a broken lock, and a medication cup was left at a resident's bedside. Staff interviews revealed lapses in procedure adherence and communication.
The facility did not maintain cleanliness in three of four unit kitchenettes, with dust and food particles on refrigerator seals and ice build-up in freezers. Staff interviews revealed a failure to adhere to cleaning protocols, with responsibilities for daily and weekly cleaning not being met.
During a survey, it was observed that dietary staff failed to follow proper infection control practices by not changing gloves or performing hand hygiene while handling various items and preparing food for residents. This was confirmed by RNs who stated that staff are educated on infection control upon hire and annually.
A resident with minimal cognitive impairment and significant assistance needs was left to soil themselves multiple times due to staff delays, leading to feelings of humiliation. The resident's care plan, which included timely assistance for toileting, was not consistently followed, and staff response times varied, contributing to the issue.
A resident was found with medications at their bedside despite not being assessed as capable of self-administration due to safety concerns. Facility staff acknowledged that medications should not be left at the bedside, yet inconsistencies in policy adherence were observed.
A resident with a history of hemiplegia and anxiety was subjected to verbal abuse and harassment by their roommate, leading to increased anxiety and sleeplessness. Despite complaints and evident distress, the facility failed to document or investigate the incidents, allowing the abuse to continue until the roommate was moved. The abusive resident had a history of aggressive behavior, yet the facility's interventions were ineffective in preventing further incidents.
A resident reported verbal abuse by their roommate, causing distress and fear. Despite the facility's policy requiring immediate reporting of abuse allegations, the incident was not reported to the Department of Health. Staff were aware of the issues, but the facility failed to take timely action, resulting in ongoing distress for the resident.
A resident reported verbal abuse by their roommate, leading to distress and fear over several months. Despite multiple reports to nursing staff, the facility failed to document or investigate the allegations, resulting in the resident's relocation. The roommate, known for inappropriate behaviors, was eventually moved, but the facility's Administrator did not consider the incidents reportable, highlighting a deficiency in handling abuse allegations.
A resident with Alzheimer's and other conditions exhibited verbal outbursts during meals, but staff failed to implement the care plan interventions to manage these behaviors. Despite attempts to manage the resident's behavior, such as medication adjustments and staff reminders, the care plan was not updated or effectively executed, resulting in a deficiency.
A resident with Parkinson's disease and a history of falls did not have their care plan updated after multiple falls, despite facility policies requiring such updates. The resident's care plan lacked new interventions following falls, and interviews with facility staff confirmed that care plans should be regularly updated to support resident needs.
A resident with insulin-dependent diabetes experienced critically high blood sugar levels, reaching 525 mg/dL, without appropriate monitoring or physician notification as required by the facility's diabetic management policy. The resident's care plan mandated blood sugar checks every 30 minutes, which were not performed, leading to the resident being hospitalized for severe hyperglycemia and sepsis. Staff interviews revealed a misunderstanding of the protocol, contributing to the deficiency.
A medication error rate of 17.86% was observed in an LTC facility due to incorrect timing and form of medication administration for a resident with a hip fracture, diverticulitis, and atrial fibrillation. The LPN administered medications late and did not crush them as required, citing short staffing as the reason for the delay. Despite training and competency assessments, the facility failed to adhere to its medication administration policy.
A resident, assessed as cognitively intact and with multiple medical conditions, reported missing a bank card, blank checks, and cash after observing a staff member in their drawer. Unauthorized charges and cashed checks were later discovered, and facility records and interviews confirmed that a Certified Nurse Aide took and used the resident's property for personal gain, in violation of the facility's abuse prevention policy.
Deficiency in Grievance Process Awareness and Accessibility
Penalty
Summary
The facility failed to ensure that residents were aware of and could access the grievance process, as evidenced by observations, interviews, and record reviews during a recertification survey. Six residents reported during a Resident Council meeting that they were unaware of the grievance process or how to file and resolve grievances. The facility's 2024 Admission Agreement and policy on complaints and grievances outlined a procedure for filing grievances, but this information was not effectively communicated to the residents. Throughout the survey, it was observed that there were no visible grievance forms, boxes for completed forms, or signage explaining the grievance process on any unit. Interviews with various staff members, including social workers and nurses, revealed inconsistencies in the availability and accessibility of grievance forms. Social workers indicated that they filled out grievance forms on behalf of residents, as many residents could not complete the forms themselves. However, there was no clear process for residents to file grievances anonymously, and staff encouraged residents to report issues directly to them, which could deter residents from filing grievances due to fear of retaliation. The facility's grievance process was not effectively communicated to residents, as evidenced by the lack of awareness among residents about the Ombudsman and the grievance filing process. Staff interviews revealed that grievances were typically handled by social workers and discussed in Quality Assurance meetings, but residents were not informed about the existence of grievance forms or how to access them independently. This lack of communication and accessibility led to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal.
Failure to Honor Resident Choice in Bathing Frequency
Penalty
Summary
The facility failed to honor the residents' right to make choices about their care, specifically regarding the frequency of bathing. Resident #15, who has multiple sclerosis and requires significant assistance with activities of daily living, expressed dissatisfaction with the frequency of their bed baths and showers. Despite being minimally cognitively impaired and able to communicate their needs, Resident #15 reported not receiving even weekly bed baths or showers, contrary to their care plan. The resident's lower legs were observed to have yellow, flaking skin, which the resident attributed to inadequate bathing. The resident had requested 2-3 showers weekly, but staff did not accommodate this request, citing logistical challenges such as the need for a lift. Similarly, Resident #60, who is cognitively intact and requires assistance with personal care, also expressed a desire for more frequent bathing than the once-weekly schedule provided. Despite preferring 4-5 showers per week, the resident's requests for additional showers were not fulfilled. Interviews with staff indicated that while efforts were made to accommodate such requests, they were not consistently successful, and residents sometimes refused showers when offered outside of regular shifts. This failure to facilitate resident choice in personal care routines constitutes a deficiency in promoting resident self-determination.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews during a recertification and abbreviated survey. The facility did not meet its minimum staffing levels on multiple shifts and units between October 8, 2024, and October 15, 2024. This deficiency resulted in numerous resident and family complaints about delayed responses to call lights and missed scheduled showers and treatments. The facility's staffing plan required 3.48 hours of direct care per resident per day, with specific allocations for Registered Nurses (RNs) and Certified Nurse Aides (CNAs). However, the actual staffing levels documented on various days showed significant shortfalls, particularly in the number of RNs and CNAs available during shifts. For instance, on several occasions, there were no Licensed Practical Nurses (LPNs) on night shifts, and the number of CNAs was often below the required levels. Residents reported long wait times for assistance, with some being left soiled for extended periods. Observations noted call bells ringing for up to 17 minutes before being answered, and strong urine odors were detected in certain areas, indicating neglect in resident care. Interviews with residents and staff confirmed the staffing issues, with residents expressing frustration over the lack of timely care and staff acknowledging the challenges of working understaffed shifts.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice. Specifically, several opened medications lacked open and expiration dates, and some had incorrect expiration dates. For instance, insulin pens on various medication carts were found with either no expiration dates or dates exceeding the manufacturer's recommendations. Additionally, a narcotic lock box was found with a broken lock, and the issue had not been addressed due to a lack of communication and follow-up by the staff. Medication carts were observed to be left unlocked and unattended on multiple occasions, which is against the facility's policy. Personal items such as eyeglasses, a watch, and a television remote were found stored in a medication cart alongside medical supplies, indicating a breach in storage protocol. Furthermore, a pre-poured medication cup was found at a resident's bedside, which is contrary to the facility's policy that requires medications to be administered directly by the nurse who prepared them. Interviews with staff revealed gaps in adherence to procedures and communication issues. Licensed Practical Nurses and Registered Nurses admitted to lapses in following the correct procedures for medication storage and administration. The Director of Nursing and Nurse Educator confirmed that all nurses undergo training and competency exams, yet the observed deficiencies suggest a disconnect between training and practice. The facility's policies were not consistently followed, leading to these deficiencies.
Deficiency in Food Service Safety Standards
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in three of four resident unit kitchenettes. Observations revealed that the kitchenettes on Units two, three, and four were not maintained in a clean condition. Specifically, the tops of refrigerators were dust-covered, and food particles were present on the freezer and refrigerator seals. Additionally, the freezer had ice build-up inside and around the seals. On Unit three, the microwave oven contained food particles, and the coffee machine had excessive build-up on its screen. On Unit four, the refrigerator and freezer door seals were cracked and broken, with an apparent attempt to correct the issue using sealant or caulking. Interviews with facility staff revealed a lack of adherence to cleaning protocols. The Director of Food Services indicated that staff were expected to clean the kitchenettes daily and sign off upon completion, while the Environmental Services Supervisor stated that their staff was responsible for weekly cleaning of the kitchenettes and refrigerator seals. However, both acknowledged that the observed conditions were unacceptable and should have been addressed or reported to maintenance. The Director of Maintenance confirmed that they were only notified of the seal issue on Unit four the day before the surveyor's observation and had since ordered new seals.
Infection Control Lapse During Meal Preparation
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed during meal preparation and serving, as observed during a recertification survey. Specifically, dietary staff did not change gloves or perform hand hygiene while handling various items and preparing food for residents. The staff member was seen touching potentially contaminated surfaces such as the warming cart cord, power switch, and resident tickets, and then proceeded to handle food items without changing gloves. This action was contrary to the facility's documented Infection Prevention and Control and Antibiotic Stewardship Plan, which mandates ongoing education for all personnel on infection control and the use of Standard Precautions. Interviews with Registered Nurses confirmed that the dietary staff's actions were inappropriate and not in line with infection control practices. Both Registered Nurse #2 and Registered Nurse #3 acknowledged that the dietary staff should not have worn the same gloves after touching dirty objects and then handling food. They also confirmed that staff receive education on infection control upon hire, annually, and as needed when on-the-spot education is required. Despite this training, the observed actions of the dietary staff indicated a lapse in following proper infection control protocols.
Resident Dignity Compromised Due to Delayed Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner, as evidenced by the experiences of Resident #29. The resident, who was minimally cognitively impaired and required significant assistance with activities of daily living, was left to soil themselves on multiple occasions due to staff not attending to their needs in a timely manner. The resident reported that the facility was short-staffed, leading to delays in receiving showers and assistance after bowel movements, which left them feeling humiliated. The resident's care plan included interventions to maintain dignity and hygiene, such as providing access to a call bell and responding quickly to toileting needs, but these were not consistently followed. Interviews with the resident and staff revealed that the resident frequently had to wait for assistance, particularly after meals when staff were occupied in the dining room. The resident expressed that the response time to their call bell varied depending on which staff members were on duty. The Director of Nursing acknowledged that chronic conditions should be care planned for all residents and that Registered Nurses were responsible for updating care plans. However, there was no clear standard for how long residents should wait for assistance, with the Director of Nursing unable to specify an acceptable response time.
Failure to Assess and Monitor Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team appropriately assessed a resident's ability to self-administer medications. Specifically, a resident with a history of cutaneous abscess, atrial fibrillation, and difficulty walking was observed with medications at their bedside, including Tylenol, Voltaren cream, and ALI probiotics. The resident's care plan indicated they were not a candidate for self-administration due to safety concerns, and there were no documented physician orders for some of the medications found at the bedside. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, a Nurse Educator, and the Director of Nursing, revealed inconsistencies in the understanding and implementation of the facility's medication administration policies. Staff acknowledged that medications should not be left at the bedside and that no residents were allowed to self-medicate. However, medications were still found at the resident's bedside, indicating a lapse in adherence to the facility's policies and procedures regarding medication storage and administration.
Failure to Protect Resident from Verbal Abuse and Harassment
Penalty
Summary
The facility failed to protect a resident from verbal abuse and harassment by their roommate, leading to a deficiency in ensuring residents are free from abuse, neglect, and exploitation. The affected resident, who had a history of hemiplegia, hemiparesis, and anxiety, reported feeling terrified and experiencing sleeplessness due to threatening remarks made by their roommate. Despite the resident's complaints and the evident increase in anxiety medication usage, the facility did not document an incident report or conduct an investigation into the allegations. The facility's inaction continued as the resident was moved next door to the same abusive roommate, resulting in ongoing harassment. The resident continued to experience distress, as documented in psychotherapy progress notes, and reported incidents of the roommate entering their room and turning on the lights. The facility's failure to adequately address the situation and protect the resident from further abuse was evident, as the abusive behavior persisted until the roommate was eventually moved to a separate unit. The abusive roommate had a documented history of verbal aggression and inappropriate behavior towards other residents and staff. Despite being placed on behavioral contracts and receiving counseling, the resident continued to exhibit aggressive behaviors. The facility's lack of timely and effective intervention allowed the abusive behavior to continue, impacting the safety and well-being of the affected resident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #60 in a timely manner, as required by regulations. Resident #60, who was admitted with conditions including hemiplegia, anxiety, and major depressive disorder, reported verbal abuse by their roommate, Resident #69. Despite the facility's policy mandating immediate reporting of abuse allegations, the incident was not reported to the Department of Health. The facility's Comprehensive Care Plan aimed to protect Resident #60 from abuse, but interventions were insufficient to prevent the ongoing distress caused by Resident #69. Resident #60 experienced significant distress due to the actions of Resident #69, who made derogatory comments and engaged in disruptive behaviors. Progress notes documented multiple instances where Resident #60 expressed fear and discomfort due to Resident #69's behavior, including verbal abuse and inappropriate actions like turning on lights at night. Despite these reports, the facility's response was delayed, and Resident #60 continued to feel unsafe for an extended period. Interviews with staff revealed awareness of the issues between Resident #60 and Resident #69, yet the facility did not take timely action to address the situation or report it to the appropriate authorities. The facility's administration and social workers were aware of Resident #69's problematic behavior but did not consider it reportable. This oversight resulted in a failure to protect Resident #60 from ongoing abuse and neglect, violating their right to a safe and secure environment.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving Resident #60, who reported being verbally abused by their roommate, Resident #69. The incident was initially reported on 3/18/2024, when Resident #60 informed a Licensed Practical Nurse that Resident #69 made disparaging comments, calling them derogatory names. Despite the report, there was no documented evidence of an investigation or incident report being completed by the facility. This lack of documentation persisted even after Resident #60 expressed fear and distress over the situation, leading to their relocation to another room. Resident #60, who was cognitively intact but required significant assistance with daily activities due to conditions such as hemiplegia and chronic pain, continued to experience distress from the verbal abuse. The resident reported feeling unsafe and anxious for several months, despite informing nursing staff of the ongoing verbal abuse and inappropriate behavior by Resident #69. The facility's failure to act promptly and investigate the allegations left Resident #60 feeling vulnerable and fearful until Resident #69 was eventually moved to another unit. Resident #69, who also had a history of inappropriate behaviors and verbal outbursts, was involved in multiple incidents with staff and other residents. Despite these ongoing issues, the facility's Administrator did not consider the incidents reportable and failed to provide any incident reports or investigations. This oversight highlights a significant deficiency in the facility's response to allegations of abuse, as required by their own policies and federal/state regulations.
Failure to Implement Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with Alzheimer's Disease, chronic kidney disease, and asthma. The care plan, which was supposed to address the resident's behavioral issues, was not effectively executed. During meal times, the resident exhibited verbal outbursts and used foul language in the dining room, but staff did not intervene to manage these behaviors as outlined in the care plan. The care plan included interventions such as encouraging decreased verbal outbursts and using slow and reassuring techniques, but these were not implemented during the observed incidents. Interviews with staff revealed that while there were attempts to manage the resident's behavior, such as reminding the resident to be nice and removing them when agitated, these actions were inconsistent and not in line with the documented care plan. The staff also mentioned working with psychiatry to adjust medications, as the resident's behavior reportedly worsened after starting a new medication. Despite these efforts, the care plan was not updated to reflect these changes or to provide clear guidance on managing the resident's behavior, leading to a deficiency in meeting the resident's needs.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised with measurable objectives, time frames, and appropriate interventions for a resident with a history of falls. Specifically, the care plan for the resident's Safety Awareness Deficit was not updated following multiple falls on several dates throughout 2024. Despite having a policy in place that required follow-up evaluations after significant changes in condition, the care plan lacked new interventions after certain falls, indicating a failure to adhere to the facility's own policies. The resident involved was admitted with diagnoses including Parkinson's disease, hallucinations, and pulmonary hypertension. The resident was minimally cognitively impaired and required some assistance with activities of daily living. Although there were physician's orders for evaluations by occupational and physical therapy, the care plan was not consistently updated to reflect these interventions. Interviews with the Director of Nursing and the Administrator confirmed that care plans should be updated regularly to support resident needs, yet this was not done in this case.
Failure to Monitor and Manage Diabetic Resident's Blood Sugar
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who had insulin-dependent type 2 diabetes mellitus, experienced a critically high blood sugar level of 525 mg/dL in the morning. Despite the facility's diabetic management policy requiring immediate assessment and notification of a physician for blood sugar levels over 400 mg/dL, there was no documented evidence of such actions being taken. The resident's care plan also required blood sugar monitoring every 30 minutes until levels normalized, but this was not adhered to, as no vitals were recorded between 9:00 AM and 4:28 PM. Later in the day, the resident's blood sugar was recorded as 600 mg/dL, and the resident was eventually transported to the hospital with symptoms of severe hyperglycemia and sepsis. Interviews with facility staff revealed a misunderstanding of the protocol, with a registered nurse indicating that blood sugar rechecks were not necessary unless symptoms were present, contrary to the care plan's requirements. The Director of Nursing acknowledged that blood sugar levels over 500 mg/dL required closer monitoring, highlighting a gap in the facility's adherence to its own protocols.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 17.86% error rate during a medication pass observation. This deficiency was identified during a recertification survey involving Resident #106, who was observed receiving medications at incorrect times and in incorrect forms. The resident, who was cognitively intact, had a medical history including a hip fracture, diverticulitis, and atrial fibrillation. The physician's orders specified that certain medications should be administered at specific times and in crushed form, but these instructions were not followed by the LPN administering the medications. During the medication pass, the LPN administered several medications late and did not crush medications as required by the physician's orders. The LPN attributed the delay to short staffing and did not notify the physician of the late administration, choosing instead to administer the medications at their discretion. The facility's policy on medication administration emphasizes the importance of adhering to the 5 Rights of Medication Administration, but these were not observed in this instance. Interviews with the Director of Nursing and Nurse Educator revealed that staff received training and competency assessments in medication administration, yet the deficiency occurred, indicating a lapse in adherence to established protocols.
Misappropriation of Resident Property by Staff Member
Penalty
Summary
A resident with diagnoses of depression, asthma, and chronic obstructive pulmonary disease, who was assessed as cognitively intact, reported missing personal property including a bank card, blank checks, and cash from their room. The resident noticed a staff member, a Certified Nurse Aide, in their drawer and later received unauthorized notifications of charges and cashed checks. The resident reported the missing items and unauthorized transactions to facility staff, including a nurse and a social worker. The facility's records and interviews confirmed that the resident's bank card and checks were used without authorization, resulting in financial loss. The facility's Abuse Prevention and Investigation Policy states that residents have the right to be free from exploitation and misappropriation of property. Despite this, the Certified Nurse Aide was identified through video footage and police review as the individual responsible for taking the resident's belongings and using them for personal gain. The incident was reported to law enforcement and the Department of Health, and the facility's investigation corroborated the resident's account of the misappropriation.
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Illustrative
What surveyors actually found near you
We read the 179 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Guilderland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grand Rehabilitation And Nrsg At Guilderland | 2.9 mi | ★★★★★ | 0 | 0 |
| Daughters Of Sarah Nursing Center | 4 mi | ★★★★★ | 1 | 0 |
| Teresian House Nursing Home Co Inc | 4 mi | ★★★★★ | 0 | 0 |
| Eddy Village Green At Beverwyck | 4.6 mi | ★★★★★ | 2 | 0 |
| Kingsway Arms Nursing Center Inc | 5.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.