Cycle 1
Health 2023-04-13 · Fire 2023-04-13
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Oswego, NY
St Luke Residential Health Care Facility Inc
1-star overall rating with 1-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
299 East River Road, Oswego, NY
(315) 342-3166
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
139
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-05-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.69
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.44
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.42
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,360
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.88
Baseline 16.27% · Performance 18.24% · Measure score 6.88 · Achievement 6.88 · Improvement 0
Healthcare-associated infections
0
Baseline 5.15% · Performance 8.38% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.91
Baseline 49.22% · Performance 47.69% · Measure score 3.91 · Achievement 3.91 · Improvement 0.13
Adjusted total nurse staffing
0
Baseline 3.12 hours · Performance 2.96 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 182 · Observed rate 8.79% · Lower 95% interval 7.74% |
| Discharge to community | 49.03% |
50.57%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 189 · Observed rate 43.39% · Lower 95% interval 41.61% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.06% |
95.27%
8.2 pts worse
|
Numerator 175 · Denominator 201 |
| Falls with major injury | 0.5% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 201 |
| Discharge self-care score | 61.31% |
53.69%
7.6 pts better
|
Numerator 84 · Denominator 137 |
| Discharge mobility score | 68.61% |
50.94%
17.7 pts better
|
Numerator 94 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 2.99% |
2.29%
0.7 pts worse
|
Numerator 6 · Denominator 201 · Adjusted rate 3.57% |
| Healthcare-associated infections requiring hospitalization | 8.38% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 138 · Observed rate 9.42% · Lower 95% interval 5.06% |
| Staff COVID-19 vaccination coverage | 7.25% |
8.2%
0.9 pts worse
|
Numerator 14 · Denominator 193 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 68.61% |
56.45%
12.2 pts better
|
Numerator 94 · Denominator 137 |
| Transfer of health information to provider | 96.08% |
95.95%
0.1 pts better
|
Numerator 49 · Denominator 51 |
| Transfer of health information to patient | 97.17% |
96.28%
0.9 pts better
|
Numerator 103 · Denominator 106 |
| Resident COVID-19 vaccinations up to date | 37.5% |
25.2%
12.3 pts better
|
Numerator 33 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.4% |
91.2%
15.8 pts worse
|
93.4%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.6% · Q2 80.5% · Q3 71.3% · Q4 59.6% · 4Q avg 75.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.3% |
95.3%
7 pts worse
|
95.5%
7.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.0%
0.3 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.1% · Q3 2.5% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
18.5%
15.3 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.3% · Q3 2.6% · Q4 2.7% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
6.1%
About the same
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.3% · Q3 12.9% · Q4 4.9% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.7% |
13.5%
7.2 pts worse
|
19.6%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 18.1% · Q3 19.7% · Q4 20.2% · 4Q avg 20.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
14.8%
1.5 pts worse
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 17.5% · Q3 15.1% · Q4 11.6% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.8% |
15.1%
4.7 pts worse
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 14.1% · Q3 23.9% · Q4 34.4% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.9% |
15.5%
2.4 pts worse
|
14.9%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 13.4% · Q3 22.1% · Q4 24.8% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.6%
1.5 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.7% · Q3 1.6% · Q4 3.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
1.4%
3.9 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 4.8% · Q3 6.9% · Q4 3.7% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
20.8%
0.9 pts worse
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 32.9% · Q3 17.5% · Q4 23.0% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
6.9%
1.8 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.3% · Q3 10.4% · Q4 10.8% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.6% |
76.7%
26.1 pts worse
|
81.7%
31.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 56.7% · Q3 33.1% · Q4 29.8% · 4Q avg 50.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
9.7%
1.7 pts worse
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.0% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.3% |
78.8%
14.5 pts worse
|
79.7%
15.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
20.6%
1.6 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 17.3% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-09 · Fire 2021-04-09
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-01-18 · Fire 2019-01-18
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-05-05
E · Potential for more than minimal harm
2023-04-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-10
D · Potential for more than minimal harm
2023-04-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-10
F · Potential for more than minimal harm
2021-04-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-06-07
F · Potential for more than minimal harm
2021-04-09
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-04-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-04-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-04-09
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-04-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-04-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-06-07
F · Potential for more than minimal harm
2019-01-18
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2019-03-18
E · Potential for more than minimal harm
2019-01-18
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2019-03-18
D · Potential for more than minimal harm
2019-01-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-03-18
D · Potential for more than minimal harm
2019-01-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-18
D · Potential for more than minimal harm
2019-01-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-03-18
D · Potential for more than minimal harm
2019-01-18
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-03-18
Inspection history
Recent health citations
J · Immediate jeopardy
2025-03-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-04
G · Actual harm
2025-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-04
G · Actual harm
2025-03-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-04
F · Potential for more than minimal harm
2025-03-14
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-04
E · Potential for more than minimal harm
2025-03-14
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-05-04
D · Potential for more than minimal harm
2025-03-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-04
D · Potential for more than minimal harm
2025-03-14
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-05-04
D · Potential for more than minimal harm
2023-12-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-02-25
D · Potential for more than minimal harm
2023-06-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-06-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-05-03
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-07-01
E · Potential for more than minimal harm
2023-04-13
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-11
E · Potential for more than minimal harm
2023-04-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-11
E · Potential for more than minimal harm
2023-04-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-13
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-06-11
E · Potential for more than minimal harm
2021-04-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-06-07
E · Potential for more than minimal harm
2021-04-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-06-07
E · Potential for more than minimal harm
2021-04-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-04-09
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-04-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-06-07
E · Potential for more than minimal harm
2019-01-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-03-19
D · Potential for more than minimal harm
2019-01-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-03-19
D · Potential for more than minimal harm
2019-01-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-03-19
D · Potential for more than minimal harm
2019-01-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-03-19
Penalties and ownership
What sits behind the stars
Ownership
Caswell, Brian
Corporate Director · Individual
Cullinan, Michael
Corporate Officer · Individual
Farfaglia, Richard
Corporate Director · Individual
Frawley, Stephen
Corporate Director · Individual
Gill, Catherine
Corporate Officer · Individual
Gill, Catherine
W-2 Managing Employee · Individual
Mirabito, Jerome
Corporate Officer · Individual
Nelson, Allison
Corporate Director · Individual
Pollock, Michael
Corporate Officer · Individual
Youngs, Shelly
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Pontiac Nursing Home
Oswego, NY
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
#2
Morningstar Residential Care Center
Oswego, NY
1-star overall rating with 1-star inspections with $177,503 in total fines with 13 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#3
Seneca Hill Manor Inc
Oswego, NY
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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