St Luke Residential Health Care Facility Inc

In the surveyor’s words

From the most serious findings on record at St Luke Residential Health Care Facility Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 14, 2025

  Based 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. […]

• Actual harm, isolatedF684Mar 14, 2025

  Based 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… […]

• Actual harm, isolatedF686Mar 14, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF725Mar 14, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF835Mar 14, 2025

  Based 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… […]