Inspection Reports for
St Luke Residential Health Care Facility Inc
299 East River Road, Oswego, NY, 13126
Back to Facility ProfileInspection Report — Mar 14, 2025
Complaint Investigation
Citations: 41
Date: Mar 14, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2022 to 2025 with citation and complaint history, enforcement actions, and severity details.
Complaint Details
The state logged 113 complaints about this facility; 13 led to on-site inspections. The facility received 80.4 complaints per 100 beds versus a statewide rate of 57.4. 17 citations resulted from those complaints.
Findings
Across 8 inspections, 55 citations were issued including 31 standard health and 24 Life Safety Code citations. One enforcement action with fines was recorded, and multiple deficiencies ranged from minor potential harm to immediate jeopardy.
Citations (41)
ADL Care Provided For Dependent Residents: Standard Health Citation — quality of care with pattern scope.
Administration: Standard Health Citation — quality of care with pattern scope.
Bedrails: Standard Health Citation — quality of care with isolated scope.
Bowel/bladder Incontinence, Catheter, Uti: Standard Health Citation — quality of care with isolated scope.
Develop/implement Comprehensive Care Plan: Standard Health Citation — quality of care with widespread scope.
Dialysis: Standard Health Citation — quality of care with isolated scope.
Encoding/transmitting Resident Assessments: Standard Health Citation — quality of care with pattern scope.
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care with isolated scope.
Infection Prevention & Control: Standard Health Citation — quality of care with isolated scope.
Label/store Drugs And Biologicals: Standard Health Citation — quality of care with isolated scope.
Nurse Aide Peform Review-12 Hr/yr In-service: Standard Health Citation — quality of care with isolated scope.
Nutrition/hydration Status Maintenance: Standard Health Citation — quality of care with isolated scope.
Provided Diet Meets Needs Of Each Resident: Standard Health Citation — quality of care with isolated scope.
Quality Of Care: Standard Health Citation — quality of care with isolated scope.
Request/refuse/dscntnue Trmnt;formlte Adv Dir: Standard Health Citation — quality of care with isolated scope.
Resident Rights/exercise Of Rights: Standard Health Citation — quality of care with isolated scope.
Right To Be Free From Chemical Restraints: Standard Health Citation — quality of care with pattern scope.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with isolated scope.
Sufficient Nursing Staff: Standard Health Citation — quality of care with widespread scope.
Treatment/svcs To Prevent/heal Pressure Ulcer: Standard Health Citation — quality of care with isolated scope.
Building Construction Type And Height: Life Safety Code Citation — NFPA requirements with widespread scope.
Electrical Equipment - Testing And Maintenanc: Life Safety Code Citation — NFPA requirements with isolated scope.
Hazardous Areas - Enclosure: Life Safety Code Citation — NFPA requirements with isolated scope.
Multiple Occupancies - Construction Type: Life Safety Code Citation — NFPA requirements with pattern scope.
Portable Fire Extinguishers: Life Safety Code Citation — NFPA requirements with isolated scope.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with widespread scope.
Sprinkler System - Out Of Service: Life Safety Code Citation — NFPA requirements with widespread scope.
Vertical Openings - Enclosure: Life Safety Code Citation — NFPA requirements with isolated scope.
Tube Feeding Mgmt/restore Eating Skills: Standard Health Citation — quality of care with isolated scope.
Notify Of Changes (injury/decline/room, Etc. ): Standard Health Citation — quality of care with isolated scope.
Treatment/svcs To Prevent/heal Pressure Ulcer: Standard Health Citation — quality of care with isolated scope.
Respect, Dignity/right To Have Prsnl Property: Standard Health Citation — quality of care with isolated scope.
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care with pattern scope.
Infection Control: Standard Health Citation — quality of care with scope.
Infection Prevention & Control: Standard Health Citation — quality of care with pattern scope.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with pattern scope.
Treatment/service For Dementia: Standard Health Citation — quality of care with isolated scope.
Means Of Egress - General: Life Safety Code Citation — NFPA requirements with isolated scope.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with pattern scope.
Reporting - National Health Safety Network: Standard Health Citation — quality of care with widespread scope. Not yet corrected.
Reporting - National Health Safety Network: Standard Health Citation — quality of care with widespread scope. Not yet corrected.
Report Facts
Inspections on page: 8
Total violations/deficiencies cited: 55
Inspections with violations: 7
Inspections without violations: 1
Plan of correction counts: Not explicitly stated
Total fines: 26000
Number of enforcement actions: 1
Inspection Report — Mar 14, 2025
Annual Inspection
Citations: 7
Date: Mar 14, 2025
Visit Reason
The survey was a recertification and abbreviated survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and care, treatment and care for pressure ulcers, nutrition and hydration, staffing sufficiency, accident hazards related to elopement risk, and food service quality. Several residents experienced inadequate care, including failure to provide timely toileting, proper wound care, adequate nutrition, and sufficient supervision to prevent accidents.
Citations (7)
F 0550: The facility failed to ensure Resident #508's right to a dignified existence as their bedside commode was not emptied timely, resulting in malodorous and visible urine and feces near the resident and visitors.
F 0684: Resident #136 did not receive treatment and care according to professional standards, including missed tube feedings, improper medication administration, lack of hygiene, isolation, and lack of stimulation, resulting in actual harm.
F 0686: Residents #60, #67, and #113 with pressure ulcers did not receive consistent and adequate wound care, including delayed treatment, failure to follow wound physician recommendations, improper dressing use, and infection control breaches, resulting in actual harm.
F 0689: Resident #85 eloped through an unsecured window due to lack of adequate supervision and window security, placing the resident and others at immediate jeopardy of serious harm or death.
F 0725: The facility failed to provide sufficient nursing staff to meet resident needs and ensure safety, with documented staffing shortages and staff reports of being overwhelmed, impacting quality of care for all residents.
F 0800: Resident #25's lunch meal was served at unsafe temperatures and was unpalatable; the 6th floor breakfast meal was delayed resulting in unappetizing food temperatures; food storage and equipment maintenance deficiencies were also noted.
F 0835: Administration failed to ensure effective and efficient use of resources, allowing multiple deficient practices including accident hazards, insufficient staffing, and poor quality of care to persist.
Report Facts
Residents requiring assistance of two: 52
Facility census: 149
Food temperatures: 124.3
Food temperatures: 104.2
Food temperatures: 55.2
Food temperatures: 59.4
Food temperatures: 48.7
Food temperatures: 47.5
Food temperatures: 137
Food temperatures: 119.3
Food temperatures: 117.4
Food temperatures: 53.1
Food temperatures: 52.2
Food temperatures: 58.8
Food temperatures: 57.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #36 | Licensed Practical Nurse | Named in findings related to missed tube feedings and improper medication administration for Resident #136. |
| Certified Nurse Aide #44 | Certified Nurse Aide | Named in findings related to Resident #136's care including missed shower and repositioning. |
| Registered Nurse Unit Manager #31 | Registered Nurse Unit Manager | Named in findings related to wound care and staffing management. |
| Physician Wound Consultant #30 | Physician Wound Consultant | Named in findings related to wound care recommendations not followed. |
| Food Service Director | Food Service Director | Named in findings related to food temperature and food storage deficiencies. |
| Administrator | Administrator | Named in findings related to administration deficiencies and elopement incident. |
Inspection Report — Dec 28, 2023
Abbreviated Survey
Citations: 1
Date: Dec 28, 2023
Visit Reason
The abbreviated survey was conducted to evaluate compliance with care standards related to feeding tube management for residents, specifically focusing on Resident #1's treatment and services to prevent complications from enteral feeding.
Findings
The facility failed to ensure timely implementation of physician orders to decrease tube feeding rate and water flushes for Resident #1, resulting in episodes of vomiting, feeling full, and other complications. The order change was not faxed to the pharmacy promptly, causing delays in care adjustments.
Citations (1)
F 0693: The facility did not ensure a resident fed by enteral means received appropriate treatment to prevent complications such as aspiration pneumonia, vomiting, and dehydration. The physician's orders to decrease the tube feeding rate and water flushes were not implemented timely.
Report Facts
Tube feeding rate: 80
Tube feeding total volume: 1440
Tube feeding rate: 60
Tube feeding total volume: 1080
Water flush volume: 150
Water flush volume: 100
Weight increase: 7
Residual volume: 600
Residual volume: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 16 | Registered Nurse | Responsible for faxing order change to pharmacy; did not fax the order on 12/1/2023 |
| Physician 12 | Attending Physician | Signed the order to reduce tube feeding rate and flushes on 12/1/2023 |
| Registered Dietitian 11 | Registered Dietitian | Recommended decreasing tube feeding rate and flushes; monitored resident's tube feeding tolerance |
| Assistant Director of Nursing | Assistant Director of Nursing | Documented resident's complaints and feeding issues; interviewed about feeding pauses |
Inspection Report — Jun 9, 2023
Abbreviated Survey
Citations: 2
Date: Jun 9, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with regulations related to resident care, specifically focusing on pressure ulcer care, notification of significant changes to residents or their representatives, and wound treatment.
Findings
The facility failed to notify a resident's representative of significant changes in treatment related to deep tissue injuries (DTIs) and did not ensure appropriate treatment and care plan updates for residents with pressure ulcers. Documentation and communication deficiencies were noted, and some wounds worsened without timely intervention.
Citations (2)
F 0580: The facility did not ensure the resident's representative was notified when there was a need to alter treatment significantly for Resident #4 with deep tissue injuries to bilateral heels.
F 0686: The facility did not ensure residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers for Residents #2 and #4. Care plans were not updated and treatment orders were incomplete or missing.
Report Facts
Deficiencies cited: 2
Wound measurements: 6.5
Wound measurements: 5
Wound measurements: 4.5
Wound measurements: 3.5
Wound measurements: 2.7
Wound measurements: 1.5
White blood cell count: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Unit Manager #5 | Registered Nurse Unit Manager | Responsible for skin assessments and family notifications; could not recall notifying family of new heel wounds |
| Wound Care RN #6 | Wound Care Registered Nurse | Provided wound assessments and treatment recommendations; did not notify family of heel wounds |
| LPN #13 | Licensed Practical Nurse | Documented wound conditions and treatments on 5/18/21 |
| NP #19 | Nurse Practitioner | Approved treatment orders and provided clinical evaluation |
| RN #18 | Registered Nurse | Documented wound assessments and family communications in February 2023 |
| LPN #7 | Licensed Practical Nurse | Documented family reports and wound observations in February 2023 |
| CNA #9 | Certified Nurse Aide | Reported skin issues to nurses and communicated family concerns |
| CNA #8 | Certified Nurse Aide | Notified nurse of skin issues and applied barrier cream |
Inspection Report — May 3, 2023
Abbreviated Survey
Citations: 1
Date: May 3, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with residents' rights, specifically regarding the use and retention of personal possessions, including cell phone access for Resident #72.
Findings
The facility failed to ensure Resident #72's right to retain and use their personal cell phone, which was repeatedly removed by staff due to inappropriate use. This removal impacted the resident's ability to communicate with family and others outside the facility.
Citations (1)
F 0557: The facility failed to honor Resident #72's right to be treated with respect and dignity by removing their personal cell phone, limiting their communication with family and others. The phone was taken away multiple times due to non-emergent and inappropriate use despite care plan interventions.
Report Facts
Residents Affected: 1
PHQ-9 score: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Documented removal of Resident #72's cell phone and participated in interviews |
| SW #2 | Social Worker | Documented multiple progress notes regarding Resident #72's cell phone removal and care planning |
| LPN #1 | Licensed Practical Nurse | Documented progress notes and interviewed regarding Resident #72's cell phone removal |
| Director of Nursing | Director of Nursing | Interviewed about staff expectations and care planning related to Resident #72's cell phone removal |
| Physician #5 | Physician | Provided medical perspective on Resident #72's condition and cell phone removal |
Inspection Report — Apr 6, 2023
Annual Inspection
Citations: 4
Date: Apr 6, 2023
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 4/6/23 to 4/13/23 to assess compliance with regulatory requirements for nursing home operations, resident care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including environmental maintenance with damaged walls and nonfunctional sinks; inadequate supervision to prevent resident-to-resident altercations involving residents with dementia and behavioral issues; failure to provide appropriate dementia care plans; and lack of an effective infection prevention and control program, specifically missing Legionella policies and testing.
Citations (4)
F 0584: The facility failed to maintain a safe, clean, and homelike environment with damaged walls, nonfunctional medication room sinks wrapped in gauze and tape, damaged ceilings, and dangling light fixtures across multiple floors.
F 0689: The facility failed to provide adequate supervision to prevent accidents and physical altercations among residents with behavioral issues, resulting in multiple incidents involving Residents #81, #84, #95, and #110.
F 0744: The facility failed to provide appropriate treatment and services to a resident with dementia by not having an individualized care plan that included the resident's routines, preferences, and choices to guide staff in managing care.
F 0880: The facility failed to maintain an infection prevention and control program by lacking a policy and procedure for Legionella risk reduction and not conducting required annual Legionella culture sampling and analysis.
Report Facts
Residents affected: 5
Residents affected: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding environmental deficiencies and maintenance work order process | |
| Director of Nursing | DON | Interviewed regarding facility rounds, supervision, and care plan oversight |
| Physician #19 | Physician | Interviewed regarding Resident #110's dementia and behavioral management |
| Nurse Manager | Responsible for incident investigations and care plan updates | |
| Infection Preventionist | IP | Interviewed regarding infection control program and Legionella testing |
| Administrator | Interviewed regarding Legionella testing policies and facility oversight |
Inspection Report — Apr 7, 2021
Annual Inspection
Citations: 5
Date: Apr 7, 2021
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for St Luke Residential Health Care Facility Inc.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, timely resolution of resident grievances, proper labeling and storage of medications, maintaining food temperatures within safe ranges, and infection prevention and control practices.
Citations (5)
F 0584: The facility did not maintain a safe, clean, and homelike environment in 7 nursing units, with issues such as peeling paint, loose handrails, stained ceiling tiles, missing wall tiles, and unclean light fixtures.
F 0585: The facility failed to make prompt efforts to resolve a resident grievance regarding missing property, with no documented evidence of active resolution.
F 0761: The facility did not ensure insulin pens in medication carts were labeled with the date opened, risking improper medication use for 2 medication carts observed.
F 0804: The facility did not ensure food and drink were served at safe and appetizing temperatures during 3 meals, with hot foods and cold beverages outside acceptable temperature ranges.
F 0880: The facility failed to maintain infection prevention and control in 5 soiled utility rooms where water nozzles were submerged in unclean water, posing a risk of cross contamination.
Report Facts
Residents Affected: 7
Residents Affected: 1
Residents Affected: 2
Residents Affected: 3
Residents Affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding environmental deficiencies and unaware of issues | |
| Registered Nurse Unit Manager #14 | RN Unit Manager | Interviewed regarding resident grievance |
| Social Worker #14 | Social Worker | Interviewed regarding resident grievance and reimbursement |
| Director of Social Services | Director of Social Services | Interviewed regarding resident grievance and reimbursement |
| LPN #11 | Licensed Practical Nurse | Observed insulin pen labeling issue on Unit 5 medication cart |
| LPN #12 | Licensed Practical Nurse | Observed insulin pen labeling issue on Unit 6 medication cart |
| Director of Nursing | Director of Nursing | Interviewed regarding insulin pen labeling policy |
| RN Unit Manager #10 | RN Unit Manager | Interviewed regarding insulin pen labeling |
| Food Service Director | Food Service Director | Interviewed regarding food temperature standards |
| Food Service Supervisor #1 | Food Service Supervisor | Interviewed regarding food temperature observations |
| Housekeeping Supervisor | Interviewed regarding soiled utility room sink usage | |
| Maintenance Director | Maintenance Director | Interviewed regarding infection control issues with water nozzles |
Inspection Report — Jan 18, 2019
Annual Inspection
Citations: 4
Date: Jan 18, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for a nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, inadequate treatment and care for skin conditions, failure to provide assistive devices for mobility, and improper food storage and labeling in kitchenettes.
Citations (4)
F 0578: The facility did not ensure 2 of 6 residents had the right to formulate advance directives as required. Specifically, Medical Orders for Life-Sustaining Treatment (MOLST) were completed by health care proxies without documented determination of residents' decision-making capacity by attending and concurring physicians.
F 0684: The facility did not ensure 1 of 1 resident reviewed for skin conditions received appropriate treatment. Resident #29 sustained a skin tear with no physician orders or care planned interventions to promote healing.
F 0688: The facility did not provide appropriate care to maintain or improve range of motion for 1 of 6 residents. Resident #106 was not provided with assistive devices (carrot splints) as ordered for hand contractures.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards. Multiple kitchenette refrigerators contained outdated or unlabeled food items, violating food safety policies.
Report Facts
Residents reviewed for advance directives: 6
Residents reviewed for skin conditions: 1
Residents reviewed for range of motion: 6
Kitchenettes with food safety issues: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| OT #25 | Occupational Therapist | Expected nursing staff to follow orders for carrot splints for Resident #106 |
| LPN #33 | Licensed Practical Nurse | Responsible for checking carrot splints placement and documentation for Resident #106 |
| CNA #31 | Certified Nurse Aide | Responsible for placing carrot splints for Resident #106 |
| Director of Social Services | Interviewed regarding capacity determinations for advance directives | |
| RN Unit Manager #27 | Registered Nurse Unit Manager | Interviewed regarding capacity determinations for advance directives |
| RN Unit Manager #28 | Registered Nurse Unit Manager | Interviewed regarding capacity determinations and carrot splints for Resident #106 |
| Nurse Practitioner #29 | Nurse Practitioner | Interviewed regarding capacity determinations for advance directives |
| Physician #30 | Physician | Interviewed regarding capacity determinations for advance directives |
| Food Service Director | Interviewed regarding food safety and refrigerator monitoring | |
| Food Service Manager | Interviewed regarding food labeling and expiration dates | |
| Dietary Staff #1 | Responsible for checking refrigerators on resident units |
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