Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Luke Residential Health Care Facility Inc during CMS and state inspections, most recent first.
A cognitively impaired resident at risk for elopement did not have a care plan in place, leading to their elopement through an unsecured window. The resident, diagnosed with dementia and schizophrenia, was found at a nearby facility. The facility's policy required an elopement assessment and care plan, but these were not documented. Windows lacked limiters, allowing the resident to exit. Staff interviews confirmed inadequate window security and lack of specific interventions for the resident's behaviors.
A resident in an LTC facility did not receive appropriate care and treatment as per physician orders and facility policies. The resident, who relied on a gastrostomy tube for nutrition, was not given the correct volume of tube feeding and water flushes. Medications were ordered orally despite a 'nothing by mouth' status. The resident was improperly positioned during feedings, and their catheter bag was placed on the floor. They did not receive scheduled showers, were left undressed, and had no accessible call bell, leading to physical and psychosocial harm.
The facility failed to provide adequate care for residents with pressure ulcers, resulting in harm. A resident developed a stage 4 ulcer on their hip without proper treatment, another had a heel ulcer untreated for 11 days, and a third was observed without a dressing on their heel ulcer. Physician recommendations were not consistently implemented, and residents were not repositioned as required.
The facility was found to have insufficient nursing staff, leading to delays in call bell responses and inadequate care for residents. Deficiencies were noted in areas such as activities of daily living, quality of care, pressure ulcer treatment, and nutrition. Residents reported long wait times for assistance, and staff expressed being overwhelmed due to low staffing levels. The administration acknowledged the staffing challenges, which affected the quality of care provided.
The facility was cited for deficiencies in accident hazards, quality of care, pressure ulcer treatment, and nutrition/hydration maintenance. Staffing shortages affected resident care, and the quality assurance plan was not effectively implemented. An elopement incident occurred due to a lack of checks on wander prevention devices.
A resident with a tibia fracture experienced a lack of dignity due to the facility's failure to regularly empty their bedside commode, resulting in visible and malodorous waste. Despite being cognitively intact, the resident expressed concerns about the persistent odor, which was confirmed by staff interviews. The RN Unit Manager expected the commode to be emptied after each use, but it was often neglected, especially during busy shifts, leading to an unsanitary and embarrassing situation for the resident.
The facility failed to provide residents with meals at appropriate temperatures, as observed with a resident's lunch and the 6th floor breakfast, both served below acceptable temperature ranges. Additionally, food items in the kitchen were not dated, and a non-functional cooler lacked proper signage, compromising food safety.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who was cognitively impaired and at risk for elopement. The resident, who had diagnoses including dementia, schizophrenia, and delusional disorder, did not have a care plan in place addressing their elopement risk. Despite being identified as an elopement risk upon admission, the resident did not have an individualized care plan to address this risk. On a specific date, the resident eloped from the facility through an unsecured window and was found at a nearby skilled nursing facility. The facility's policy required an elopement assessment to be completed within 24 hours of admission and at other specified times, with an individualized plan of care developed for residents at risk. However, there was no documented evidence of such a care plan for the resident in question. The resident had previously expressed a desire to leave the facility and had been experiencing increased anxiety, yet no specific interventions were implemented to address these behaviors. The windows in the resident's room were not adequately secured, allowing the resident to push out the screen and exit through the window. Interviews with staff revealed that the windows on the units did not have limiters prior to the elopement, and maintenance checks were only conducted when a resident moved out. After the elopement, temporary measures were taken to secure the windows, but these were not immediately replaced with more permanent solutions. The lack of a care plan and inadequate window security contributed to the resident's ability to elope, posing a risk of serious harm due to the facility's location near a main road and a river.
Removal Plan
- The facility's immediate plan was reviewed and accepted.
- 100% of all staff currently working have been educated on elopement risk and window securement.
- 85% of staff had been educated on elopement risk and window securement.
- The remaining staff will be educated prior to the start of their next shift or upon return from their leave.
- Staff education was verified onsite during interviews. Multiple staff including nursing, maintenance, housekeeping, and activities were interviewed.
- Staff were able to report content of education, confirmed the day they received the education, and the facility staff who presented the education.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care for Resident #136, as evidenced by multiple deficiencies observed during the survey. The resident, who had a gastrostomy tube for feeding, did not receive the prescribed volume of tube feeding and water flushes as ordered by the physician. Additionally, medications that were supposed to be administered via the tube were instead ordered to be given orally, despite the resident's 'nothing by mouth' status. The resident was also improperly positioned during tube feeding, increasing the risk of aspiration. Resident #136, who had a history of depression, obstructive uropathy, cerebral infarction with left hemiplegia, and dysphagia, was not provided with adequate activities of daily living care. The resident was left in their room with the door closed, the call bell out of reach, and no alternative call system provided. The resident's catheter collection bag was improperly placed on the floor, and they did not receive their scheduled weekly shower or hair washing. Furthermore, the resident was observed in bed for consecutive days without being dressed, and their gastrostomy tube insertion site was visible from the hallway, compromising their dignity. The facility's failure to adhere to its policies and procedures resulted in physical and psychosocial harm to Resident #136. The resident was not engaged in preferred activities for sensory stimulation and was left without timely care, leading to feelings of loneliness and isolation. The facility's policies on activities of daily living, fall prevention, and call bell accessibility were not followed, contributing to the deficiencies observed during the survey.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, leading to significant deficiencies in care. Resident #60, who had a history of dysphagia and stroke with left-sided weakness, developed a stage 4 pressure ulcer on their right hip. Despite being at high risk for skin breakdown, the care plan interventions were not consistently followed, and there was no documented evidence of treatment being administered to the pressure ulcer. The wound physician's recommendations were not discussed or ordered by a provider, and the resident was eventually admitted to the hospital with a necrotic pressure ulcer and infection. Resident #67, who had a stage 4 pressure ulcer on their left heel, did not receive timely treatment for their wound. The facility failed to implement the wound physician's recommendations for 11 days after the ulcer was discovered. Observations during the survey revealed that the resident was not wearing their pressure relief booties as planned, and there was no evidence of the facility evaluating and implementing the physician's recommendations to promote healing. Resident #113, who had a stage 3 pressure ulcer on their right heel, was observed without a dressing on their wound. The resident frequently removed their socks and dressings, and staff failed to address this issue or inform a nurse. The lack of a dressing on the wound could lead to worsening of the wound or potential infection. The facility's failure to ensure proper wound care and follow-up on physician recommendations resulted in actual harm to the residents, although it was not considered immediate jeopardy.
Inadequate Staffing Leads to Deficiencies in Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as observed during a recertification survey. Residents reported that call bells were not answered in a timely manner, particularly during the night shift, leading to situations where residents were left in distress. The staffing levels were inadequate to provide necessary assistance with activities of daily living, such as bathing, dressing, and toileting, which affected the quality of care provided to the residents. Specific deficiencies were identified in several areas, including Activities of Daily Living, Quality of Care, Treatment/Services to Prevent and Heal Pressure Ulcers, and Nutrition/Hydration Status Maintenance. For instance, some residents did not receive showers as planned, were not assisted at meals, or were not toileted in a timely manner. Additionally, residents with pressure ulcers did not receive appropriate treatment, and there were lapses in following care plans and professional standards, leading to the development and inadequate treatment of pressure ulcers. Interviews with staff and residents highlighted the challenges faced due to low staffing levels. Staff reported being overwhelmed and unable to provide adequate care, with some having to work overtime frequently. The facility's staffing plan was not sufficient to cover the needs of the residents, particularly during evenings, nights, and weekends. This lack of adequate staffing was acknowledged by the facility's administration and medical director, who noted that it affected the quality of care provided to the residents.
Deficiencies in Care and Staffing at LTC Facility
Penalty
Summary
The facility was found to have several deficiencies during a recertification and abbreviated survey. The administration failed to ensure that residents received appropriate quality of care, leading to deficiencies in accident hazards, quality of care, treatment and services to prevent pressure ulcers, and nutrition/hydration status maintenance. Specifically, the facility did not maintain a safe environment free from accident hazards for one resident, failed to provide treatment and care in accordance with professional standards for another, and did not ensure necessary treatment and services for residents with pressure ulcers. Additionally, the facility did not maintain acceptable nutritional status for two residents. The facility also failed to ensure sufficient nursing staff to maintain the highest practicable physical, mental, and psychosocial well-being of residents. The administrator acknowledged challenges in providing quality care due to staffing shortages. The facility's quality assurance plan was not effectively implemented, as there were no audits in place for residents with weight loss or quality of care issues. The administrator noted that staffing and scheduling were ongoing challenges, and there were no orders in place to check the functionality of wander prevention devices, which contributed to an elopement incident.
Failure to Maintain Dignity and Cleanliness for Resident
Penalty
Summary
The facility failed to ensure a dignified existence for Resident #508, as evidenced by the improper management of the resident's bedside commode. Observations revealed that the commode was not emptied regularly, resulting in urine and feces being visible and malodorous. The resident, who had a fracture of the right tibia and required assistance with personal care, was cognitively intact and expressed concerns about the persistent odor due to insufficient staff to empty the commode. The resident's care plan included the use of a commode, but the care instructions did not document this, leading to a lack of proper management. Interviews with staff, including a CNA and an LPN, confirmed that the commode was often not emptied after use, particularly during busy shifts. The CNA noted that the commode was not emptied by the overnight shift, and the LPN acknowledged that it was unsanitary for the resident to eat meals next to a soiled commode. The RN Unit Manager expected the commode to be emptied after each use for cleanliness and infection control, highlighting the dignity issue and the embarrassment caused to the resident when visitors were present. The failure to maintain a clean and dignified environment for the resident was a clear deficiency in the facility's care practices.
Deficiency in Meal Service and Food Storage
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. During the recertification survey, it was observed that Resident #25's lunch meal was not served at an appetizing temperature, with the cheeseburger, onion rings, macaroni salad, mandarin oranges, water, and milk all measuring below the acceptable temperature range. The resident reported that mealtimes were inconsistent, and the food was often cold and hard, even when alternative meals were requested. Additionally, the breakfast meal on the 6th floor was delivered 30 minutes late, resulting in unappetizing food temperatures. The last meal tray was passed at 9:07 AM, with items such as scrambled eggs, toast, and milk measuring below the facility's standard for palatability. The delay was attributed to a staff member dropping a tray of drinks, and the unit was informed of the delay. During a kitchen tour, it was found that multiple food items were not dated when opened, and a cooler was not in working order, lacking signage to indicate it should not be used. The cooler contained an oral nutrition supplement and had a temperature gauge reading of 57 degrees Fahrenheit. The Food Service Director acknowledged the importance of labeling and dating food items for safety and stated that equipment not in working order should have signage to prevent use. The cooler had been reported as non-functional, but the sign indicating it was out of order was missing.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 43 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oswego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pontiac Nursing Home | 0.1 mi | ★★★★★ | 30 | 0 |
| Morningstar Residential Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Seneca Hill Manor Inc | 3.7 mi | ★★★★★ | 1 | 0 |
| Syracuse Home Association | 22.1 mi | ★★★★★ | 12 | 0 |
| The Cottages At Garden Grove, A Skilled Nrsg Comm | 25.1 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.