Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
OUR LADY OF MERCY LIFE CENTER
GUILDERLAND, NY · 160 certified beds · Last Life Safety survey October 15, 2024
CMS Certification Number 335767 · first certified July 1993
Ownership
Operated by TRINITY HEALTH · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NY
7 citations — more than 17% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 1. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: April 2026 to November 2026. This facility’s last Life Safety survey was October 2024. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 7 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 7 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 7 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 13, 2019 | 1 |
| February 14, 2022 | 1 |
| October 15, 2024 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 2 | 2024-10-15 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-10-15 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2024-10-15 |
| E-0007 | Address patient/client population and determine types of services needed. | 1 | 2024-10-15 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2024-10-15 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Smoke Deficiencies 1
- Services Deficiencies 1
- Emergency Preparedness Deficiencies 1
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Smoke Deficiencies | 1 |
| Services Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 15, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 13, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (December 2, 2024) |
February 14, 2022 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 7, 2022) |
August 13, 2019 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (October 1, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.