St. Luke Residential Health Care Facility Inc

Inspectors wroteBased on observations, record review, and interviews during the recertification, abbreviated (NY00359628), and extended surveys conducted 3/4/2025 - 3/14/2025, the facility failed to ensure adequate supervision to prevent accidents for one (1) of six (6) residents (Resident #85) reviewed. Specifically, Resident #85 was cognitively impaired, was at risk for elopement, and did not have a care plan in place addressing their elopement risk. Subsequently, Resident #85 eloped from the facility on 11/5/2024 through an unsecured window and was located at a skilled nursing facility approximately 1/4 mile away and across the street from a river. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00330552) surveys conducted 3/4/2025 - 3/14/2025, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of two (2) residents (Resident #136) reviewed. Specifically, Resident #136: - physician's order for gastrostomy (a tube placed in the stomach) tube feeding was not administered as ordered and when administered was the incorrect volume; - had an order to receive nothing by mouth and medications were ordered to be given orally; - was improperly positioned prior to having a tube feeding administered; - had an indwelling catheter collection bag in a permeable pillowcase laying on the floor; - did not receive their weekly shower or hair washing; [...]

Inspectors wroteBased on record review, observations, and interviews during the recertification and abbreviated (NY00332457) surveys conducted 3/4/2025 - 3/14/2025, 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 new ulcers from developing for three (3) of four (4) residents (Residents #60, #67, and #113) reviewed. Specifically, Resident #60 developed a stage 4 (full-thickness skin loss with exposed bone, tendon or muscle) pressure ulcer to their right hip. Care plan interventions were not consistently followed to prevent pressure ulcers from developing and when the pressure ulcer developed it was not adequately treated to prevent infection. [...]

Inspectors wroteBased on observations, record reviews, and interviews during the recertification survey and abbreviated (NY00330552) surveys conducted 3/4/2025- 3/14/2025, the facility did not ensure sufficient nursing staff to ensure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for all 149 residents in the facility. Specifically, during a confidential resident group meeting residents stated staffing was not sufficient, and call bells were not answered timely especially during the night shift. Deficiencies related to staffing levels were identified in the areas of Activities of Daily Living (F677), Quality of Care (F684), Treatment/Services to Prevent and Heal Pressure Ulcer (F686), and Nutrition/Hydration Status Maintenance (F692).

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated survey (NY00330552 and NY00359628) conducted 3/4/2025- 3/10/2025, and the recertification extended survey conducted 3/10/2025-3/14/2025, the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, administration failed to ensure that residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death, F 689 Accident Hazards; failed to ensure policies and procedures were properly identified, communicated, and consistently implemented. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 3/4/2024-3/14/2025, the facility did not ensure each resident had the right to a dignified existence for 1 of 4 residents (Resident #508) reviewed. Specifically, Resident #508's bedside commode was not emptied, and urine and feces were malodorous and visible in plain sight.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 3/4/2025- 3/14/2025, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 2 of 2 meals observed. Specifically, Resident #25's lunch meal was not served at a palatable, flavorful, and at an appetizing temperature, and the 6th floor breakfast meal was delivered to the unit 30 minutes after the scheduled time with the last meal tray was passed at 9:07 AM, resulting in unappetizing food temperatures. Additionally, during the initial main kitchen tour multiple food items were not dated when opened; [...]

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00330259), the facility did not ensure a resident who was fed by enteral means (tube fed) received the appropriate treatment and services to prevent complications of enteral feed including but not limited to aspiration (inhalation of food/fluids into the lungs) pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 experienced symptoms related to their tube feeding and the physician's orders to decrease the tube feeding rate and water flushes was not implemented timely.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00278069) surveys conducted 4/6/23-4/13/23, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 5 of 5 occupied resident floors (1st floor, 4th floor, 5th floor, 6th floor, and 7th floor) reviewed. Specifically, the 6th and 7th floor medication rooms had nonfunctional sinks; the 4th and 6th floor dining rooms had damaged walls; the 6th floor tub room had a damaged wall; the 1st and 5th floor shower rooms had damaged walls; resident room B112 had a damaged ceiling; and the 1st floor women's staff locker room had a dangling overhead ceiling light.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00297818, NY00286515, NY00306767, NY00313104, and NY00313529) surveys conducted 4/6/23-4/13/23, the facility failed to ensure residents received adequate supervision to prevent accidents for 4 of 7 residents (Residents #81, 84 and 95 and 110) reviewed. Specifically: - Resident #110 had ongoing wandering and aggressive behaviors and was not provided adequate supervision resulting in multiple physical altercations with other residents including Residents #81, 84 and 95. - Resident #81 had an impulse disorder and was not provided adequate supervision resulting in physical and verbal altercations with other residents including Residents #110.

Inspectors wroteBased on record review and interview during the recertification survey conducted 4/6/23-4/13/23, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including Legionella (a type of bacteria usually found in water which causes Legionnaires' disease). Specifically, the facility did not have a policy and procedure to reduce the risk of growth and spread of Legionella in the building water system; and Legionella culture sampling and analysis of the facility's potable water system was not conducted annually as required.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/6/23-4/13/23 the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #137) reviewed. Specifically, Resident #137 did not have an individualized care plan with interventions in place that included the resident's customary routines, interests, preferences, and choices to enhance their well-being and to guide staff in managing the resident's care.

Inspectors wroteBased on observation and interview during the recertification survey, the facility did not maintain a safe, clean, comfortable, and homelike environment for 7 of 7 nursing units (Units 1B, 2, 3, 4, 5, 6 and 7) reviewed. Specifically, resident areas including bedrooms, shower rooms, and common areas were found with loose handrails, stained ceiling tiles, discolored ice machines, missing wall tiles, unclean light fixtures, peeling paint, unfinished window framing and holes in the ceiling.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 meals (breakfast, lunch, and dinner) reviewed. Specifically, meal temperatures were not maintained at acceptable parameters when tested during 3 meals.

Inspectors wroteBased on observation and interview during the recertification survey, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 7 soiled utility rooms (Units 1B, 2, 3, 4 and 6) observed. Specifically, soiled utility room sinks were observed with the water nozzle located inside the hopper, under unclean water, necessitating staff to reach in the water to retrieve the nozzle.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure the facility made prompt efforts to resolve resident grievances for 1 of 2 residents (Resident #118) reviewed. Specifically, there was no documented evidence the facility was actively working towards a resolution after Resident #118 reported missing property.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 (Units 5 and 6) medication carts observed. Specifically, Units 5 and 6 medication carts contained insulin pens that had been opened and were not dated.

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure 2 of 6 residents (Residents #62 and 106) reviewed for advance directives, had the right to formulate advance directives. Specifically, Residents #62 and 106 had Medical Orders for Life-Sustaining Treatment (MOLST) completed by a health care proxy (HCP, a person designated to make health care decisions for someone determined to lack capacity for decision making) and there was no documentation the residents lacked decision-making capacity.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure 1 of 1 resident (Resident #29) reviewed for skin conditions, received treatment and care in accordance with professional standards of practice. Specifically, Resident #29 sustained a skin tear to her leg and there were no ordered treatments or care planned interventions to promote healing.

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not ensure 1 of 6 residents (Resident #106) reviewed for range of motion (ROM), received appropriate services and equipment to maintain or improve mobility. Specifically, Resident #106 was not provided with assistive devices for hand contractures (stiffness in the connective tissues) as care planned.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in 4 of 6 kitchenettes (Units 5, 6 and 7). Specifically, multiple kitchenette refrigerators contained items that were outdated or were not labeled.