St Luke Residential Health Care Facility Inc

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

F-F684

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

F-F686

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 42 335746 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 The facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent Level of Harm - Minimal harm or new ulcers from developing for 3 of 4 residents. potential for actual harm Nutrition/Hydration Status Maintenance, Refer to the citation under

F-F689.

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

F-F692 Residents Affected - Some

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

F-F725

The facility failed to ensure sufficient nursing staff to ensure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for 12 of 12 anonymous residents.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 42 335746