Inspection Reports for
Our Lady of Mercy Life Center
2 Mercycare Lane, Guilderland, NY, 12084
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 19
Date: Oct 15, 2024
Visit Reason
Complaint Survey with 15 health citations and 5 life safety code citations, all corrected by December 2024.
Findings
Complaint Survey with 15 health citations and 5 life safety code citations, all corrected by December 2024.
Deficiencies (19)
Care plan timing and revision
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Free from abuse and neglect
Grievances
Infection prevention & control
Investigate/prevent/correct alleged violation
Label/store drugs and biologicals
Quality of care
Reporting of alleged violations
Resident rights/exercise of rights
Resident self-admin meds-clinically approp
Self-determination
Sufficient nursing staff
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Elevators
Ep program patient population
Fire alarm system - installation
Inspection Report
Annual Inspection
Census: 146
Deficiencies: 2
Date: Oct 15, 2024
Visit Reason
The inspection was a recertification survey and abbreviated survey to assess compliance with regulatory requirements, including care planning and staffing adequacy.
Findings
The facility failed to develop and implement comprehensive person-centered care plans for residents, specifically Resident #62, whose behavior interventions were not implemented during meals. Additionally, the facility did not ensure sufficient nursing staff to meet resident needs, resulting in delayed call light responses and unmet care needs.
Deficiencies (2)
F 0656: The facility did not develop and implement a complete care plan with measurable objectives and timeframes for Resident #62, whose behavior interventions were not followed during meals.
F 0725: The facility failed to provide enough nursing staff daily to meet resident needs, with staffing shortages noted on multiple shifts and units between 10/08/2024 and 10/15/2024, causing delayed responses to call lights and missed scheduled care.
Report Facts
Residents present: 146
Staffing hours per resident per day: 3.48
Registered Nurse hours per resident per day: 0.55
Certified Nurse Aide hours per resident per day: 2.45
Deficiency counts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing #1 | Director of Nursing | Discussed care plan updates and staffing challenges related to Resident #62's behaviors and facility staffing |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Provided information on Resident #62's behaviors and staff interventions |
| Registered Nurse #4 | Registered Nurse | Described staff actions for Resident #62's behaviors and medication management |
| Unit Manager #1 | Unit Manager | Discussed Resident #62's behavior onset related to medication and staff interventions |
| Registered Nurse #2 | Nurse Educator | Described behavior team meetings and staff education |
| Social Worker #1 | Social Worker | Discussed shower requests and staffing communication |
| Administrator #1 | Administrator | Discussed staffing recruitment efforts and resident communication |
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Oct 15, 2024
Visit Reason
Recertification survey and abbreviated survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and timely assistance, medication self-administration assessment, resident choice in personal care, grievance process awareness, abuse prevention and reporting, care plan development and updates, medication administration errors, staffing shortages, medication storage and labeling, food safety and sanitation, and infection control practices.
Deficiencies (15)
F 0550: Resident #29 was left to soil themselves due to staff not responding timely, causing humiliation and dignity violations.
F 0554: Resident #29's ability to self-administer medications was not periodically assessed; medications were found at bedside without proper orders.
F 0561: Residents #15 and #60 were repeatedly denied requests for more frequent bathing despite documented preferences and needs.
F 0585: Residents were unaware of grievance procedures; grievance forms were not readily accessible and residents lacked knowledge of filing complaints.
F 0600: Resident #60 experienced verbal abuse and harassment from roommate Resident #69, causing fear and anxiety; facility failed to report abuse to authorities and conduct thorough investigation.
F 0610: Facility failed to thoroughly investigate allegations of verbal abuse reported by Resident #60 against Resident #69.
F 0656: Resident #62's behavior care plan was not implemented during observed verbal outbursts in the dining room.
F 0657: Resident #23's Safety Awareness Deficit Care plan was not updated following multiple falls between 3/13/2024 and 9/04/2024.
F 0684: Resident #2 had a blood sugar of 525 with delayed monitoring and treatment; no documented rechecks every 30 minutes as required, resulting in hospital admission for severe sepsis and hyperglycemia.
F 0725: Facility failed to provide sufficient nursing staff on multiple shifts and units between 10/08/2024 and 10/15/2024, resulting in delayed call light responses and resident complaints.
F 0759: Medication error rate was 17.86% during observed medication pass; included late medication administration without physician notification and failure to follow medication administration policies.
F 0761: Nursing staff received required training and competency testing on medication administration prior to administering medications.
F 0761: Nursing staff completed 3-5 day classroom training including medication administration and documentation, with annual competency training.
F 0812: Drugs and biologicals were not properly labeled with open or expiration dates; medication carts were left unlocked; personal items stored in medication carts; narcotic lock box had broken lock.
F 0880: Dietary staff failed to follow infection control practices by not changing gloves when handling food and touching non-food surfaces.
Report Facts
Medication error rate: 17.86
Residents present: 146
Blood sugar: 525
Blood sugar: 600
Medication pass delay: 95
Call light response time: 16
Call light response time: 9
Call light response time: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #7 | Registered Nurse | Interviewed regarding Resident #29's bowel and medication issues |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding care plans, staffing, and medication administration |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about medication self-administration knowledge |
| Registered Nurse #5 | Registered Nurse | Interviewed about medication administration rights |
| Nurse Educator #1 | Nurse Educator | Interviewed about nurse training and competencies |
| Social Worker #1 | Social Worker | Interviewed about grievance process and Resident #69 behavior |
| Administrator #1 | Administrator | Interviewed about grievances, staffing, and Resident #69 behavior |
| Registered Nurse #8 | Registered Nurse | Interviewed about blood sugar monitoring and medication administration |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed and interviewed during medication pass |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about medication cart lock and insulin pen expiration |
| Director of Food Services #1 | Director of Food Services | Interviewed about kitchenette cleaning |
| Environmental Services Supervisor #1 | Environmental Services Supervisor | Interviewed about kitchenette cleaning |
| Director of Maintenance #1 | Director of Maintenance | Interviewed about refrigerator seal repairs |
| Registered Nurse #2 | Registered Nurse | Interviewed about dietary infection control |
| Registered Nurse #3 | Registered Nurse | Interviewed about dietary infection control |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Sep 20, 2024
Visit Reason
Complaint Survey with 1 health citation related to free from misappropriation/exploitation, corrected by November 2024.
Findings
Complaint Survey with 1 health citation related to free from misappropriation/exploitation, corrected by November 2024.
Deficiencies (1)
Free from misappropriation/exploitation
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 20, 2024
Visit Reason
The abbreviated survey was conducted to investigate allegations of misappropriation of resident property and exploitation involving Resident #4.
Complaint Details
The investigation was complaint-related, triggered by Resident #4's report of missing bank card and blank checks. The complaint was substantiated based on interviews, video footage, and police involvement.
Findings
The facility failed to ensure Resident #4 was free from misappropriation of property and exploitation. Certified Nurse Aide #1 was found to have taken Resident #4's blank checks and bank card, cashing checks totaling $726.00 and making unauthorized purchases totaling $76.89.
Deficiencies (1)
10NYCRR 415.4(b) Protect each resident from the wrongful use of the resident's belongings or money. The facility did not ensure Resident #4 was free from misappropriation of property and exploitation by Certified Nurse Aide #1 who cashed checks and used the resident's bank card without authorization.
Report Facts
Amount cashed from checks: 726
Unauthorized charges: 76.89
Cash amount missing: 40
Number of residents reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Identified as responsible for misappropriation of Resident #4's property | |
| Director of Nursing #1 | Reported the incident to police and Department of Health | |
| Social Worker #1 | Assisted Resident #4 with reporting and fraud documentation | |
| Administrator #1 | Reported contacting law enforcement and staff education |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jan 13, 2023
Visit Reason
Complaint Survey with 2 health citations related to infection prevention & control and resident allergies, corrected by 2023 and earlier.
Findings
Complaint Survey with 2 health citations related to infection prevention & control and resident allergies, corrected by 2023 and earlier.
Deficiencies (2)
Infection prevention & control
Resident allergies, preferences, substitutes
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Feb 14, 2022
Visit Reason
Complaint Survey with 8 health citations and 1 life safety code citation, all corrected by April 2022.
Findings
Complaint Survey with 8 health citations and 1 life safety code citation, all corrected by April 2022.
Deficiencies (9)
Definitions
Develop/implement comprehensive care plan
Dialysis
Dispose garbage and refuse properly
Food procurement,store/prepare/serve-sanitary
Laboratory services
Nutrition/hydration status maintenance
Resident records - identifiable information
Electrical systems - essential electric syste
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Feb 14, 2022
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in developing and implementing comprehensive person-centered care plans for multiple residents, timely and accurate nutritional monitoring, dialysis care coordination, laboratory specimen collection, food service safety, garbage disposal, and medical record documentation.
Deficiencies (7)
F 0656: The facility did not develop and implement complete care plans with measurable objectives for five residents, failing to address specific medical and psychosocial needs such as elimination, oxygen use, skin integrity, and activities of daily living.
F 0692: The facility did not ensure acceptable nutritional status parameters for Resident #52 by failing to obtain and document weights according to professional standards and facility policy.
F 0698: The facility failed to provide safe and appropriate dialysis care for Resident #47, lacking ongoing assessments, monitoring, communication with the dialysis center, and a dialysis care plan.
F 0770: The facility did not ensure timely laboratory services for Resident #50, delaying stool sample collection for C-diff testing and failing to notify the physician when samples could not be obtained.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards, including an automatic dishwashing machine operating below required temperature and water pressure, unclean floors, and damaged cabinetry.
F 0814: The facility did not properly dispose of garbage and refuse, with dumpsters soiled, missing drain plugs, and open doors, risking pest harborage and feeding.
F 0842: The facility failed to maintain accurate and complete medical records for three residents, including inconsistent CNA documentation and incomplete records reflecting a resident's sudden decline and treatment decisions consistent with MOLST orders.
Report Facts
Residents reviewed for care plans: 25
Residents reviewed for nutrition: 6
Residents reviewed for dialysis care: 1
Residents reviewed for laboratory services: 1
Days without CNA documentation: 15
Days without CNA documentation: 15
Days without CNA documentation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #2 | RNUM | Named in dialysis care deficiency and Resident #130 care documentation. |
| Registered Nurse Unit Manager #3 | RNUM | Named in dialysis care deficiency. |
| Director of Nursing | DON | Interviewed regarding care plan development, weight monitoring, stool sample collection, and documentation issues. |
| Certified Nursing Assistant #1 | CNA | Observed and interviewed regarding care plan adherence and stool sample collection. |
| Licensed Practical Nurse #2 | LPN | Documented Resident #130 decline and interviewed about care. |
| Medical Director | MDir | Interviewed regarding Resident #130 end-of-life care decisions. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 15, 2021
Visit Reason
Covid-19 Survey with 1 health citation related to reporting - national health safety network, widespread and not corrected as of report.
Findings
Covid-19 Survey with 1 health citation related to reporting - national health safety network, widespread and not corrected as of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 8, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with food safety and sanitation standards in the facility.
Findings
The facility failed to store, prepare, distribute, and serve food according to professional standards, with raw foods improperly stored above ready-to-eat foods and multiple kitchen surfaces and equipment unclean. Additionally, the facility did not properly dispose of garbage and refuse, with trash compactor areas unclean and dumpsters improperly covered.
Deficiencies (2)
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards. Raw pork was stored above fully cooked eggs, and raw chicken was stored above pasteurized eggs; multiple kitchen surfaces and equipment were unclean.
F 0814: The facility did not dispose of garbage and refuse properly. The trash compactor area was unclean, one dumpster lid was broken with a 1-foot hole, and another dumpster lid was open with waste inside.
Report Facts
Dumpster hole size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Stated that improperly stored food and cleaning will require more staff education | |
| Plant Operations Manager | Stated dumpsters should be kept closed and will contact vendor to replace broken lid |
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