St Luke Residential Health Care Facility Inc
ST LUKE RESIDENTIAL HEALTH CARE FACILITY INC in OSWEGO, NY — inspection on March 14, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F677)
Based on observations, record review, and interviews the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for Residents #41, #65, and #87.
There was no documented evidence Resident #41 received showers as care planned; Resident #65 did not receive assistance at meals as care planned; Resident #87 was not toileted in a timely manner and did not receive toileting assistance as care planned; and Resident #87 missed an activity due to staff not getting them up.
Quality of Care (refer to
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 2 residents.
Treatment/Services to Prevent/Heal Pressure Ulcer, Refer to the citation text under
335746
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 335746 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Luke Residential Health Care Facility Inc 299 East River Road Oswego, NY 13126
The facility failed to ensure the residents' environment remained free of accident hazards for 1 of 6 residents reviewed.
Quality of Care, Refer to the citation text under
The facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 3 residents.
Sufficient Nursing Staff, Refer to the citation under
During an interview on 3/11/2025 at 1:12 PM, the Administrator stated upon admission residents were assessed for elopement risk and this was done each quarter as well. Resident #85 was determined to be an elopement risk on admission 6/17/2024 and at that time a wander prevention device was place on the resident.
The resident had removed the wander guard the evening they eloped.
Prior to becoming Administrator at the facility, there were no orders placed in the residents record to check that wander prevention devices were in place and working on the resident each shift.
During an interview of the Administrator on 3/13/2025 at 1:50 PM, they stated they have an average census between 140-145 residents, unit 2 remains closed and there is a registered nurse on all three shifts.
The minimum staffing for A and B wing is 2 certified nurse aides on each side and 1 licensed practical nurse; the high-rise staffing for each unit is one licensed practical nurse covers unit 4 and 5 and one licensed practical nurse covers 6 and 7, and there is one certified nurse aide on each unit.
They stated to a certain extent staffing can affect the quality-of-care residents receive. It was challenging to give good quality of care if the facility was short staffed.
During an interview on 3/14/2025 at 1:54 PM, the Administrator stated they decided what issues needed a performance improvement plan based on their audit trends and whatever was discussed in the quality assurance meetings as reported in their quality measure reports.
They were working on staffing and scheduling continuously.
They were running weekly reports on their pressure ulcers and those reports were brought to the quality assurance team.
They did not have any audits in place for residents with weight loss, or activity of daily living or quality of care issues.
10 NYCRR 483.70(i)
48675
335746
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.