Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Loretto Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with metastatic cancer, heart failure, malnutrition, and multiple existing pressure ulcers was readmitted from the hospital with detailed wound care orders and documented wounds to the sacrum, coccyx, buttock, heels, feet, ankle, and leg. On readmission, nursing documented only "impaired skin" without a full skin assessment in the Skin and Wound module, and physician orders addressed only the sacral wound VAC and heel offloading, omitting treatments for other documented ulcers. Over subsequent days, multiple electronic "Skin Issue" notes showed numerous skin areas "not evaluated," some of which were later disavowed by the RNs listed as authors, and the comprehensive care plan reflected only potential, not actual, skin impairment. Later weekly and post-hospital assessments documented numerous unstageable and Stage 4 pressure ulcers, but treatment orders were obtained for only some of these wounds, with no documented physician orders for several identified areas, including certain ankle, toe, thigh, and amputation-site ulcers. Interviews with RNs and the DON confirmed that facility policy required a head-to-toe skin assessment and Braden Scale within 24 hours of admission/readmission and same-day wound treatment orders, but in this case, assessments and documentation were incomplete and treatment orders were missing or delayed for multiple pressure ulcers.
Multiple failures were observed in maintaining a clean and safe environment, including dirty linens and soiled briefs left in resident rooms, stained ceiling tiles and privacy curtains, unclean window shades, and a soiled wheelchair. Staff interviews revealed inconsistent cleaning practices and unclear responsibilities for maintaining cleanliness and infection control in resident areas and equipment.
Surveyors identified that food was frequently served cold, bland, or overcooked, with test trays showing improper temperatures and lack of flavor. Multiple residents reported dissatisfaction with meal quality, and staff interviews confirmed ongoing complaints about food temperature and palatability. Facility policies required regular audits and proper food handling, but food preparation and delivery practices led to inconsistent results.
Mechanical lift transfers were performed by one staff member instead of the two staff members specified in the care plans for three residents. The residents were dependent for transfers and had diagnoses including stroke, weakness, and impaired mobility; one resident was severely cognitively impaired, another had severe cognitive impairment and another was cognitively intact. Observations showed CNAs transferring residents with a Hoyer lift without another staff member present, and staff interviews confirmed that the residents were supposed to receive two-person assistance per the Kardex/care plan.
Unsecured carts and expired, undated medications were found in several medication and treatment areas. Surveyors observed unlocked treatment carts, an unattended unlocked medication cart, and a medication cart screen showing resident names near the dining room. They also found expired ferrous gluconate and vitamin D, eye drops and inhalers without open dates or beyond their use period, and expired medication in a medication room. Staff stated carts should be locked when unattended and opened eye drops and inhalers should be dated and discarded per the applicable timeframe.
Food service standards were not followed in the main kitchens and several kitchenettes. Surveyors found standing water, food debris, and equipment in disrepair in the basement and second-floor kitchens, along with expired, undated, and improperly stored foods in multiple kitchenettes. The 13th-floor kitchenette also had out-of-range refrigerator temperatures, incomplete temp logs, and cold foods such as egg salad sandwiches and a frozen supplement held above acceptable temperatures.
Ineffective pest control program with fruit flies throughout the facility. The facility had ongoing fruit fly/gnat activity in the basement, 2nd floor kitchen, and multiple resident areas, with logs and vendor invoices documenting flies throughout the building and causes including trash, unclean floor drains, and food debris in the dish machine. Surveyors observed flying insects in kitchens, dining areas, hallways, a kitchenette, and a TV room, and staff reported the problem had been present for months.
Failure to Thoroughly Investigate and Report Unexplained Bruising: A resident with dementia, osteoporosis, and severe cognitive impairment developed extensive unexplained bruising to the head, shoulder, chest, and jaw, along with a clavicle fracture. Staff documented the bruising during morning care and initiated an investigation, but there was no documented RN assessment when the injuries were found. Leadership concluded the resident likely bumped into objects while ambulating and did not report the injury of unknown origin to DOH within the required timeframe.
A resident with severely impaired cognition, dependence for most ADLs, and a primary language other than English was not provided effective interpreter services despite a care plan noting the need for translation. Observations showed the resident often silent or nonresponsive, with the call bell out of reach, while staff interactions occurred without meaningful communication. Family members reported they translated for the resident during visits and never saw facility translation services used, and staff interviews showed inconsistent understanding of the resident’s language needs and no clear use of the interpreter service.
Failure to Provide Meaningful Activities: A resident with autistic disorder, anoxic brain injury, and severe cognitive impairment had documented preferences for music, TV shows, reading, outdoor time, and religious activities, but records and staff interviews showed limited 1:1 engagement and no meaningful activity program matched to those interests. Staff reported the resident was not seen participating in activities, could not view the TV from the bed/chair setup, and the RT admitted activities were forgotten during part of the month.
BiPAP mask not cleaned as ordered. A resident with OSA, chronic respiratory failure with hypoxia, and COPD used BiPAP at bedtime, and the care plan and facility policy required daily cleaning of the face mask with sterile water. Surveyors observed brown debris in the mask on multiple occasions, while the TAR showed daily cleaning was documented. An LPN later stated they had not cleaned the mask on the days they worked and should not have signed off that it was done; the RT said nursing was responsible for daily mask cleaning and described the mask as filthy.
A resident with spondylopathy, postherpetic neuralgia, and OA had a scheduled lidocaine 4% pain patch ordered for daily use, but the MAR showed the patch was not given on multiple days because it was out of stock. Nursing notes documented the supply issue, and there was no documented pre- or post-administration pain scale for the patch. The resident reported going several days without the patch and having significant back pain.
Dialysis assessments were not completed or documented as ordered for two residents receiving hemodialysis. Records showed missing pre- and post-dialysis vital signs, access-site checks, and communication book documentation, and staff interviews confirmed the expected dialysis assessment process was not consistently followed.
Failure to Use Required PPE for Enhanced Barrier Precautions: A resident with a wound and other care needs was on EBP, with signage posted and PPE available outside the room. During direct care, two CNAs wore gloves but did not wear gowns while providing hygiene and positioning, and one CNA stated they forgot to put it on. An LPN, RN Manager, and the IP all stated gowns and gloves were required for direct resident care under EBP.
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records by posting detailed identifying information in public areas. Staff confirmed that this practice violated resident rights and HIPAA regulations.
The facility failed to ensure residents were informed about the grievance process, including the ability to file anonymous grievances. Eleven residents were unaware of the grievance officer and the process for filing grievances, leading to a deficiency in honoring residents' rights.
The facility failed to ensure proper labeling and storage of medications, including unlabeled nicotine patches, expired medications, insulin without open dates, and personal food items stored with medications. Additionally, a medication room refrigerator had significant ice buildup, affecting proper medication storage.
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Pantry storage areas were soiled with food spills, and refrigerators were not cleaned. Additionally, the main kitchen tray line had cold food tables with food items at improper temperatures, and the Food Service Supervisor admitted that temperatures were not checked consistently.
The facility failed to ensure a safe, clean, and comfortable environment for residents in 6 of 14 units. Issues included overflowing laundry, dirty bathrooms, broken equipment, pest control problems, and unclean water/ice machines. Staff reported laundry and cleaning backlogs due to staffing issues, leading to undignified conditions for residents.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in meeting their medical and nursing needs. One resident with nicotine dependence was observed smoking outside without appropriate interventions in their care plan. Another resident with hemiplegia was observed without necessary pressure reduction devices, and a third resident with diabetes and stroke was seen without required pressure reducing boots.
The facility failed to ensure residents received necessary services for personal care and hygiene, leading to issues such as unkempt hair, excessive facial hair, unkept fingernails, poor meal positioning, and missed showers. Multiple residents reported discomfort and inadequate care, which was corroborated by staff interviews and observations.
The facility failed to ensure that residents received food and drink at palatable and safe temperatures. Observations and interviews revealed that cold food items on test trays were above the required temperature, making them unpalatable. Staff acknowledged the issues, and the facility's policy on food temperature control was not followed.
A resident with hemiplegia was unable to use the cold water in their bathroom sink due to the sink's placement and their physical limitations. Staff confirmed the resident's difficulty, and the facility's management acknowledged the issue, stating that all residents should have access to both hot and cold water for activities of daily living.
A resident with chronic obstructive pulmonary disease and respiratory failure experienced social isolation due to the facility's failure to consistently refill their portable oxygen tank. Despite policies requiring certified nurse aides to fill the tanks every shift, the task was often neglected, leading to the resident being confined to their room and missing activities and appointments.
The facility failed to conduct annual performance reviews for two certified nurse aides who had been employed for over 12 months. Interviews with staff revealed inconsistencies and a lack of clarity regarding the evaluation process, leading to the deficiency.
A resident with severe cognitive impairment and behavioral symptoms due to Alzheimer's disease was not provided with preferred person-centered activities. Despite the care plan's emphasis on specific music and activities, the resident was often left alone in their room with inappropriate music or no stimulation, leading to episodes of yelling and anxious restlessness. Staff interviews revealed inconsistent understanding and implementation of the care plan.
The facility failed to ensure resident dignity and hygiene for two residents. One resident was left in soiled sheets and vomit for hours despite activating the call bell, while another resident was observed with unshaven stubble, greasy hair, and an overflowing bag of dirty clothes in their room. Staff interviews confirmed that these conditions were undignified and that call bells were often not answered timely.
A resident with chronic conditions did not have an active discharge plan and was not included in care plan meetings, despite expressing interest in a lateral transfer to local nursing facilities. The facility failed to follow up on the transfer request and did not communicate the status to the resident.
The facility failed to provide adequate supervision and a safe environment for two residents. One resident fell due to unlocked bed brakes, and another resident with a history of inappropriate behaviors roamed unsupervised. Care plans and interventions were not consistently followed, leading to preventable incidents.
A resident with Alzheimer's disease and osteoarthritis did not receive adequate pain management following a fall that resulted in a hip fracture. Despite complaints of pain, there was no documented evidence of pain evaluation or management from the time of the fall until the resident was sent to the hospital. Staff interviews revealed that the nurses did not contact the provider for pain medication orders, and the family was not properly informed about the resident's condition.
The facility failed to ensure that three LPNs had the necessary competencies and skills to care for residents, as evidenced by incomplete online training, lack of annual competencies, and missing documented orientation competencies. A resident reported improper ostomy care, and staff confirmed the lack of ongoing education and competency testing.
A resident with Alzheimer's disease and osteoarthritis experienced a fall and had x-rays ordered for their left knee and hip. The x-ray results, indicating a minimally displaced fracture, were not promptly communicated to the medical provider. The delay in notification resulted in the resident experiencing pain and the family being unaware of the injury until they inquired about the results two days later.
Failure to Assess and Treat Multiple Pressure Ulcers on Readmission
Penalty
Summary
Surveyors identified that the facility failed to ensure a resident with multiple pressure ulcers received timely and complete assessment and treatment consistent with professional standards and facility policy. The resident was readmitted from the hospital with several documented pressure ulcers and specific wound care recommendations, including treatment to the sacrum, buttock, both feet, and leg wounds, as well as use of a wound VAC to the sacrum. The hospital discharge summary and the facility’s own readmission packet listed multiple pressure ulcer locations, including both heels, right lateral foot, left ankle, sacrum, coccyx, and left buttock. However, on admission, the RN admission assessment only documented “impaired skin” with a direction to see Skin and Wound for updates, and there was no documented skin assessment in the Skin and Wound section. Physician orders on readmission addressed only the sacral wound VAC and heel offloading boots, with no documented treatment orders for the other pressure ulcers identified in the hospital records and readmission packet. In the days following readmission, the electronic record contained multiple “Skin Issue” notes indicating that 25 skin issues were “not evaluated,” and several of these notes were later disavowed by the RNs whose names appeared on them. The facility’s Skin and Wound policy required pressure injury risk assessment and documentation upon admission/readmission, weekly for three weeks, and then quarterly or with changes in condition, and required that all residents with pressure injuries on admission be documented in the Skin and Wound module and reported to the provider or wound nurse. Despite this, there was no evidence that all of the resident’s wounds were assessed and entered into the Skin and Wound module upon readmission, and the comprehensive care plan only reflected a potential for skin integrity alteration, without documenting the resident’s actual existing pressure ulcers. The DON later confirmed that they did not see any wound pictures from the admission date and that they expected a full head-to-toe assessment and Braden Scale within 24 hours, with corresponding treatments and interventions. On 12/05/2025, a weekly wound assessment documented eight unstageable pressure ulcers and moisture-associated skin damage, including unstageable wounds with 100% eschar on the left heel, right 5th toe, right rear ankle, and right lateral ankle, as well as large gluteal and buttock wounds. Physician orders obtained that day addressed only the left buttock and a right rear hip blister, with no documented treatment orders for the right lateral ankle, right rear ankle, or right 5th toe. After a subsequent hospitalization, the resident returned on 12/16/2025 with documentation of 10 pressure ulcers, including unstageable wounds on both 5th toes, both heels, left rear ankle, right ankle amputation site, and left buttock fold, and Stage 4 pressure ulcers on the sacrum and right buttock. Physician orders dated 12/17/2025 implemented treatments for the heels, left and right buttock, and sacrum, but there was no documented evidence of treatment orders for the right rear thigh blister, unstageable right ankle amputation site, unstageable left rear ankle, or unstageable right and left dorsum 5th toes. Interviews with nursing staff and the DON confirmed that facility expectations were for skin assessments within 24 hours of admission/readmission and same-day implementation of wound treatments, but in this case, assessments were incomplete or not documented, and treatment orders were missing or delayed for multiple documented pressure ulcers. The resident’s clinical profile included kidney cancer with metastasis, heart failure, and malnutrition, and the most recent MDS prior to these events documented intact cognition, partial/moderate assistance needs for mobility, and existing unstageable pressure ulcers, a deep tissue injury, and moisture-associated skin damage. Despite this high-risk profile and the facility’s own policy requiring Braden Scale assessments and care plan interventions based on risk, the comprehensive care plan did not reflect the resident’s actual pressure ulcers, and there was no evidence that all wounds were entered into the Skin and Wound module or that weekly evaluations and complete treatment orders were consistently obtained. Nursing staff reported issues with the new Skin and Wound electronic application and uncertainty about why orders were not obtained for all wounds, while also acknowledging that treatments should have been ordered for all identified pressure areas during their assessments. The DON stated that for every pressure ulcer beyond Stage 1, the wound nurse and wound provider were to be involved and monitor weekly, but the documentation reviewed by surveyors showed gaps in assessment, documentation, and timely ordering of treatments for several of the resident’s pressure ulcers at multiple points in time.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures to maintain a safe, clean, and homelike environment across several resident units. Observations included dirty linens and a soiled brief left on the floor next to a resident's bed, stained ceiling tiles, and unclean privacy curtains in resident rooms. In one instance, a resident's family reported frequently seeing soiled briefs on the floor and dirty linens on the overbed table. Staff interviews confirmed that soiled linens and incontinence products should not be left on the floor, as this poses a contamination and infection control issue, but acknowledged that such items had been found and removed in the past. Additional deficiencies were observed in the maintenance and cleanliness of resident areas and equipment. Stained ceiling tiles were noted in multiple rooms, with maintenance records showing repeated tile replacements due to recurring leaks. Privacy curtains were found to be soiled, and documentation of their cleaning was inconsistent or missing. In one lounge area, bed components and electrical items were left scattered, and staff acknowledged that repairs should not have been conducted in resident areas. Window shades with visible stains were reported by a resident, who expressed embarrassment about their condition, and there was no record of cleaning or replacement for these items. Wheelchair cleanliness was also found to be lacking, with one resident's wheelchair armrests observed to be soiled with food particles. Staff interviews revealed confusion about cleaning responsibilities and schedules, with some staff believing cleaning was the responsibility of the night shift, while others stated that all staff were expected to clean dirty wheelchairs when noticed. Housekeeping logs and schedules for deep cleaning and wheelchair maintenance were inconsistent, and there was a lack of clear documentation regarding the cleaning or replacement of soiled items.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
Surveyors found that the facility failed to ensure food was served at palatable and appetizing temperatures in accordance with professional standards for food service. During the survey, test trays from two lunch meals were evaluated and found to have food items that were either not flavorful, overcooked, or served at improper temperatures. Specifically, hot foods such as pot roast and potatoes were sometimes below the recommended temperature, while cold items like juice and gelatin were above the safe cold temperature range. Residents at a council meeting reported that food was often cold, overcooked, and not palatable. Observations and interviews with staff confirmed that residents frequently complained about the quality and temperature of the food, and that alternate meals were sometimes provided when complaints were made. The facility's policies required that meals be nourishing, palatable, and served at safe and appetizing temperatures, with regular audits and test trays to monitor compliance. However, interviews revealed that food was prepared in advance, sometimes up to five days, and reheated on the units, which may have contributed to temperature inconsistencies. Staff acknowledged that food sometimes appeared overcooked or dry, and that delays in tray delivery and issues with food positioning on plates could affect temperature. Documentation and staff statements indicated that test tray temperatures were sometimes out of range, and that flavor and presentation were not consistently maintained.
Mechanical lift transfers performed with insufficient staff
Penalty
Summary
The facility did not ensure the resident environment remained free of accident hazards when three residents were transferred with a mechanical lift by one staff member instead of the two staff members required by their care plans. The survey found that Residents #5, #63, and #510 were each documented as dependent for transfers and planned for mechanical lift transfers with assistance of two staff. The facility policy stated that therapy was responsible for evaluating residents and updating transfer status, and that certified staff were not to choose a lesser mode of transfer than planned. Resident #5 had diagnoses including stroke, diabetes, and surgical after care, and the 7/4/2025 MDS documented severe cognitive impairment and dependence for chair-to-bed transfers. The care plan called for mechanical lift transfers with assistance of two. On 8/28/2025, a CNA transferred the resident from a wheelchair back to bed with a mechanical lift without another staff member present. The CNA stated the lift should be used with two people but there were not enough staff. An LPN and the unit manager stated the resident required two-person assistance and that using only one person was not appropriate. Resident #63 had diagnoses including weakness, reduced mobility, and need for assistance with personal care, and the MDS documented severe cognitive impairment and dependence for transfers. The care plan and PT evaluation both specified total dependence of two for transfers with a mechanical lift. During observation, a CNA entered the room with the lift and later the resident was found in bed with no other staff present. The CNA stated the resident was transferred back to bed alone and that this happened often when the unit was short staffed. Resident #510 had diagnoses including stroke with left-sided weakness and gait/mobility abnormalities, and the MDS documented cognitive intactness and dependence for transfers. The care plan specified dependence on two for mechanical lift transfers, yet observation showed a CNA alone with the lift and the resident later in bed. The resident stated staff always used only one person, while the CNA and unit manager stated the Kardex and care plan identified the required transfer assistance.
Unsecured carts and expired, undated medications
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional standards in multiple medication and treatment areas during the recertification survey. Surveyors found the 2nd and 4th floor treatment carts unlocked, the 6th floor medication cart unattended and unlocked near the dining room doorway, and the 4th floor medication cart screen displaying multiple resident names across from the dining room while residents were waiting for lunch. The facility’s policy stated medication carts and supplies were to be locked when not attended, and staff interviews confirmed carts were expected to be locked when unattended and resident information screens kept in the off position for privacy. Surveyors also found expired and undated medications and biologicals on the 5th and 7th floor medication carts and expired medication in the 5th floor medication room. On the 5th floor cart, opened ferrous gluconate and vitamin D bottles were past their manufacturer expiration dates, atropine ophthalmic solution bottles had handwritten open dates, and multiple inhalers and artificial tears lacked open dates or were expired. On the 7th floor cart, dry eye drops, olopatadine eye drops, Systane drops, and several inhalers were either undated or opened beyond the expected use period. Staff stated eye drops and inhalers should be dated when opened and discarded according to the applicable timeframe, and that carts should be checked routinely for expired medications. The report also noted the 5th floor medication room contained expired medication. Interviews with nursing staff and unit managers indicated medication carts should be locked when not in use, treatment carts should be locked when unattended, and opened eye drops and inhalers should be labeled so staff know when they expire. The facility policy required outdated, contaminated, or deteriorated medications to be removed from inventory and disposed of, and injectable drugs and biologicals to remain properly labeled.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the basement and second floor kitchens and in several kitchenettes. Surveyors observed unclean kitchen areas, standing water, and equipment in disrepair in the main kitchens, including food debris on ceiling tiles, duct tape on cooler doors, a dish machine that was not working properly and was dirty, and standing water on the floor where food was being plated. Staff stated some issues had been ongoing for months, including problems with the dish machine conveyor area and uncertainty about the source of the standing water. Several kitchenettes contained expired or improperly labeled food. The 3rd floor kitchenette had loaves of bread past expiration and one loaf with green growth. The 2nd floor kitchen and kitchenette had brown bananas, expired bread, and undated turkey subs and gluten-free bread with no expiration date. The 4th floor kitchenette had a breakfast muffin dated 8/13/2025. Staff interviews indicated that bread was supposed to be checked before being stocked, but one LPN and a food service aide stated that expired food should be discarded and that they were not sure why the bread and bananas were not removed. The 13th floor kitchenette had refrigerator temperatures above acceptable levels and incomplete temperature logs. The cooler/freezer log documented multiple days at or above 45 degrees Fahrenheit and one day with no temperature recorded. Surveyors observed the refrigerator at 62 to 66 degrees Fahrenheit and found egg salad sandwiches at 54 degrees Fahrenheit and a frozen nutritional supplement at 56 degrees Fahrenheit. Staff stated cold food items were supposed to be held between 34 and 41 degrees Fahrenheit, but there was uncertainty about who was responsible for ensuring that food in kitchenette refrigerators remained within range.
Ineffective pest control program with fruit flies throughout the facility
Penalty
Summary
The facility did not maintain an effective pest control program to keep the building free of pests in the basement, the 2nd floor kitchen, and units 3, 5, 6, 8, and 10. The facility policy required an ongoing pest control program to keep the building free of insects and rodents, but the pest sighting/evidence log documented fruit flies and gnats throughout the facility between 6/6/2025 and 8/7/2025, and pest control vendor invoices documented small flies throughout the facility from 5/31/2025 through 8/26/2025. The invoices identified contributing causes including trash in garbage cans, unclean floor drains, and food debris in the dish machine. Surveyors observed flying insects in multiple areas of the facility, including the basement and second-floor kitchens, the 6C area near the kitchen elevator, the 8C dining room and hallway areas, the 10C kitchenette and television room, and the 3C hallway. In interviews, the Food Service Director stated the facility was waiting for conveyor repairs to the dish machine area and that standing water on the tray line did not help eliminate fruit flies; the Commissary Director stated fruit flies had been present in the second-floor kitchen since mid-summer. The Director of Maintenance stated the amount of fruit flies had decreased in the kitchens and that staff were running water down drains with chemicals, while other staff reported seeing fruit flies throughout the building and described pest control as a problem.
Failure to Thoroughly Investigate and Timely Report Unexplained Bruising
Penalty
Summary
The facility did not thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for one resident who developed unexplained bruising to the head, shoulder, and upper chest. The resident had dementia, osteoporosis, severe cognitive impairment, and required supervision for walking and transfers. The resident was also at risk for falls due to poor safety awareness. The record showed no documented diagnosis of thrombocytopenia at the time of the incident, although later staff stated the resident bruised easily because of thrombocytopenia. On 3/11/2025, staff discovered bruising during morning care, including bruising to the right shoulder and right chest, and the resident’s son later pointed out bruising to the right top of the head. An LPN documented the bruising and initiated an investigation, but there was no documented evidence that the resident was assessed by an RN when the bruising was discovered. The investigation relied on staff statements and chart review, and the conclusion stated the resident may have bumped into doors while ambulating due to poor safety awareness. The record also documented bruising to the left jaw and a skin and wound evaluation showing bruises to multiple areas, including the scalp, chest, shoulder, and jaw. The resident was later evaluated by a physician assistant because of multiple new areas of ecchymosis, and the assessment documented diffuse ecchymosis across the right chest and shoulder with tenderness and guarded range of motion. X-ray findings showed a nondisplaced incompletely healed right lateral clavicular fracture. The report states there was no documented evidence that the unexplained bruising to the head, shoulder, and upper chest was reported to the New York State Department of Health within 24 hours as required. During interviews, nursing leadership stated the incident was considered an injury of unknown origin, but they decided it did not need to be reported because they believed abuse could be ruled out and the bruising was due to the resident’s usual activities.
Failure to Provide Translation Services for a Resident With Limited English Proficiency
Penalty
Summary
The facility did not ensure that Resident #63, whose primary language was not English, was provided appropriate translation services to support communication and care. The resident had diagnoses including diabetes, low back pain, and need for assistance with personal care. The 6/26/2025 MDS documented severely impaired cognition, that the resident spoke a language other than English, needed or wanted an interpreter to communicate with health care staff, and was dependent for most activities of daily living. The care plan identified a communication problem related to English being a second language with advancing dementia and included that a translator would be provided as necessary. During observations, the resident was seen in bed or in a wheelchair on multiple occasions, often silent, sleeping, or not responding to verbal engagement. The call bell was observed on the floor under the bed, under a pillow, or otherwise not readily accessible. On one observation, a CNA entered the room with a mechanical lift and there was no conversation between the resident and the CNA. Another observation noted an LPN and the ADON entering the room with washcloths, and the LPN later stated the ADON came to take a picture of the resident's healed thigh wound and that nystatin was applied under the resident's breasts and in abdominal folds. Family members stated the resident did not speak English and that staff did not engage with the resident or use translation services. They reported that they translated the resident's needs for staff during visits and that the resident was often soiled with urine and/or feces and often stated they were hungry. Staff interviews reflected inconsistent understanding of the resident's language needs: one CNA said the resident understood English but did not speak it and communicated through gestures, an LPN said the resident spoke a different language and family translated needs, and another LPN stated the resident spoke a foreign language and that staff did not know what the resident was saying. The Director of Social Work stated the facility had a contract with an interpreter service and that effective communication was important, but staff did not know why the service was not being used.
Failure to Provide Meaningful Activities
Penalty
Summary
The facility failed to provide ongoing programs to support each resident in their choice of activities for one resident reviewed. Resident #10 had diagnoses including autistic disorder, cardiac arrest, and anoxic brain damage, and the 8/14/2025 MDS documented severe cognitive impairment, dependence on staff for all ADLs, and no physical or verbal behaviors. The resident’s care plan and recreation assessments documented preferences for reading, music, favorite activities, spending time outdoors, religious activities, Black Entertainment Television, Music Television, The Fresh Prince, and watching anything with actor Will [NAME]. The 5/27/2025 quarterly Recreation Assessment stated the resident did not participate in any group activities and identified 1:1 interests such as music, hearing stories, and going outside. Recreation activity logs showed individual engagement with the Recreation Therapist on several dates in June and July and only twice in August. During observations, the resident was seen sitting alone in their room with a crime show playing, and later was in bed sleeping. When asked about the television and the program playing, the resident smiled and frowned, and when asked if they could see the television from bed they frowned and closed their eyes. During an observation and interview, a CNA stated the resident did not communicate verbally, used smiles, frowns, and head movements to communicate, and loved when staff came in the room and interacted with them; the CNA also stated they never saw activities working with the resident. An LPN stated they had never seen the Recreation Therapist do an activity with the resident and that the resident liked The Fresh Prince and music, but the chair positioning on 8/28/2025 did not allow the resident to view the television. The Director of Recreation stated they expected each resident to be offered an activity at least once a week, preferably three times a week, and after reviewing the record said more 1:1 and group activities were expected for the resident. The Recreation Therapist stated they forgot to include or offer any activities in August prior to 8/25/2025, including 1:1 activities, and said activities should have been offered in their absence.
BiPAP Mask Not Cleaned as Ordered
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident who used bilevel positive airway pressure (BiPAP) therapy. Resident #546 had diagnoses including obstructive sleep apnea, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. The resident’s comprehensive care plan included oxygen at 4 liters by nasal cannula and CPAP/BiPAP therapy, and the physician ordered BiPAP at bedtime. The facility policy required the facemask to be cleaned daily with sterile water and left to dry, and the tubing to be cleaned weekly. During observations on 8/25/2025, 8/27/2025, and 8/28/2025, the resident’s BiPAP mask was observed with brown debris in the base and throughout the mask. The treatment administration record showed daily documentation that the BiPAP face/nasal mask cushion was cleaned, including entries signed by an LPN on multiple days in August, but the LPN later stated they had not cleaned the mask on the days they worked and should not have signed off that it was done. The resident stated they cleaned the machine at home and wanted the mask cleaned in the facility. The RT stated nursing was responsible for cleaning the mask daily and described the mask as filthy and needing cleaning.
Pain Patch Not Administered and Pain Effectiveness Not Documented
Penalty
Summary
Safe, appropriate pain management was not provided for one resident who required scheduled pain treatment. The resident had diagnoses including spondylopathy, postherpetic neuralgia, and osteoarthritis, and the Minimum Data Set documented that the resident was cognitively intact, received scheduled pain medication and non-medical interventions for pain, and had moderate pain. The care plan identified acute/subacute/chronic pain related to herpes zoster/postherpetic neuralgia, osteoarthritis, and bilateral lower edema, with interventions to monitor, document, and report pain complaints or requests for pain treatment. The physician ordered a lidocaine 4% pain relief patch to the right lower extremity and back once daily, to be applied in the morning and removed 12 hours later at 8:00 PM, but the record did not include documented pre- and post-administration pain scales for the patch. The Medication Administration Record showed the patch was not administered on three consecutive days, with nursing notes stating it was out of stock. The resident stated the facility was often out of the pain patches, that they recently went four days without it, and that the patch was not applied for a few days because the supply was not ordered in time, resulting in the resident going without the patch and having a lot of back pain.
Dialysis Assessments Not Completed or Documented as Ordered
Penalty
Summary
Provide safe, appropriate dialysis care/services for residents who required dialysis was not met for two residents who received hemodialysis. The facility policy required dialysis observations, assessments, and care to be documented in the medical record on each dialysis day before dialysis and upon return, with the dialysis assessment completed prior to dialysis and after return. The cited deficiency involved Residents #7 and #336, both of whom had diagnoses including end stage kidney disease and dependence on renal dialysis, and both had care plans and physician orders for dialysis-related assessments and documentation. Resident #7 had hemodialysis three times weekly and a physician order dated 5/2/2025 directing dialysis assessments before and after dialysis on each dialysis day. The record showed only limited pre- and post-dialysis assessments documented in July and August 2025, with no documented evidence of consistent assessments on all ordered dialysis days. Staff interviews indicated nurses were expected to obtain vital signs, complete the dialysis communication form, assess the access site, and document the assessments before and after dialysis, but the unit manager stated they did not review whether the assessments and communication book sheets were completed and were unaware that most of the resident’s assessments were missing. Resident #336 also had hemodialysis ordered three times weekly, with care plan interventions including dialysis, dietary consultation, and lab work. The record contained no documented vital signs or assessment on the dialysis interfacility transfer patient report for June, July, or August 2025, and the dialysis communication book contained only limited pre-dialysis documentation with no post-dialysis information. Interviews with nursing staff confirmed that residents receiving dialysis were expected to have vital signs and access-site assessments documented before leaving and upon return, but one nurse stated they only took vital signs when the resident returned and did not assess the fistula or portacath or document anything in the communication book.
Failure to Use Required PPE for Enhanced Barrier Precautions
Penalty
Summary
The facility did not establish and maintain an infection 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 one resident on enhanced barrier precautions. Resident #282 had diagnoses including a right below knee amputation, intact cognition, dependence for mobility, toileting hygiene, bathing, and dressing, moderate assistance needs for personal hygiene, occasional bladder incontinence, frequent bowel incontinence, an unstageable pressure ulcer, and surgical wounds. The resident’s care plan and Kardex documented enhanced barrier precautions related to the amputation and wound, with gown and glove use required for high-contact care activities such as dressing, bathing, toileting, and hygiene. During observation, Certified Nurse Aides #56 and #57 provided personal hygiene and positioning care while wearing gloves but not surgical gowns, despite two enhanced barrier precautions signs posted outside the room and PPE being available nearby. An LPN stated the resident was on enhanced barrier precautions due to an open area and that staff should wear a gown and gloves during care, and she observed that neither aide was wearing a gown. The CNA stated they forgot to put the gown on before caring for the resident. The RN Manager and the RN Infection Preventionist both stated staff should wear gowns and gloves during direct resident care for enhanced barrier precautions.
Violation of Resident Privacy and Confidentiality
Penalty
Summary
The facility did not ensure the privacy and confidentiality of residents' personal and medical records for eight residents. Specifically, personal identifying information for these residents was posted in public areas on multiple floors, including dining rooms and near kitchen areas. The information included details such as room numbers, names, lab information, primary payor, bed status, diet, diet and liquid texture, and aspiration risks. These postings were observed on several occasions during the survey period, and the information was visible to anyone in those areas. Interviews with various staff members, including registered nurses, the Director of Social Work, the Director of Nursing, and the Director of Health Information, confirmed that the posted information was a violation of resident rights and the Health Insurance Portability and Accountability Act (HIPAA). Staff acknowledged that the information should have been covered and only accessible to authorized personnel. Despite annual and orientation training on HIPAA, the facility's practice of posting detailed resident information in public areas was not compliant with privacy regulations.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility did not ensure that information on filing grievances was available to residents, as evidenced by the statements of 11 anonymous residents during a Resident Council meeting. These residents were unaware of who the grievance officer was and did not know they could file grievances anonymously. The facility's policy stated that residents would be informed of their right to file grievances at admission and that this information would be posted throughout the facility. However, the residents reported that they were told to report concerns to their social worker and did not always receive follow-up on their grievances. Additionally, the compliance officer's contact information was not documented on the posted signs, and the residents were not aware of the process for filing anonymous grievances. Interviews with the Director of Nursing, Director of Social Work, and the Administrator revealed inconsistencies and gaps in the grievance process. The Director of Nursing stated that grievances could be filed through various means, including anonymously, but the residents were not aware of these options. The Director of Social Work was unaware of a process for filing anonymous grievances, and the Administrator believed that the compliance officer's number was in the resident handbook, but this information was not readily accessible to the residents. These findings indicate a failure to properly inform and facilitate the grievance process for residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal.
Deficiencies in Medication Labeling and Storage
Penalty
Summary
The facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles. Specifically, the medication cart on Unit 3 had nicotine patches without resident labels, and Unit 4 had expired medications. Unit 8 had insulin without a labeled open date, and Unit 10 had inhalers not in the correct pharmacy box and without labeled open dates, as well as unlabeled eye medications. Additionally, Unit 13 had personal food items stored with resident medications, and the medication room on Unit 5 had a refrigerator with significant ice buildup. During observations and interviews, it was found that the nicotine patch on Unit 3 was not labeled, which could lead to medication errors. On Unit 13, a glazed donut was found stored in the medication cart, which was confirmed by the Unit Manager to be inappropriate. Unit 4 had three bottles of expired medications, and the LPN confirmed that these should have been checked and removed. Unit 8 had two vials of open insulin without labeled open dates, and the LPN acknowledged the importance of knowing the open date for effectiveness. Further observations revealed that Unit 10 had two inhalers and other medications without labeled open dates, which should have been discarded due to the lack of labeling. The medication room on Unit 5 had a refrigerator with significant ice buildup, and the temperature logbook indicated that the refrigerator was not maintained within the required temperature range. The RN Unit Manager confirmed the importance of maintaining appropriate temperatures for medication storage.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in four of fourteen food preparation and pantry storage areas and in the main kitchen. Specifically, the pantry storage areas on multiple units were soiled with food spills, and the refrigerators were not cleaned of food debris and spills. Observations revealed that the coolers and refrigerators in these areas had old food spills, sticky floors, and visibly soiled surfaces. The Director of Housekeeping stated that the housekeeping staff and Nurse Manager were responsible for keeping these areas clean, but the required cleanliness was not maintained. Additionally, the main kitchen tray line had cold food tables with food items at temperatures ranging from 40 to 55 degrees Fahrenheit, which did not meet the facility's policy requirement of 45 degrees or lower. The Food Service Supervisor admitted that the temperatures of the food items were not checked consistently throughout the day, and several food items were found to be out of the acceptable temperature range. The food items, including chicken, pears, pureed burger, pureed hot dog, ground hot dog, ground chicken, American cheese, and pureed macaroni and cheese, were all intended for meal service but were not within the acceptable temperature ranges, indicating a failure in maintaining proper food safety standards.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 6 of 14 resident units reviewed. On Unit 3, room conditions included overflowing laundry bags, visibly dirty bathrooms with strong urine odors, and sticky floors. Residents reported a lack of staff to wash clothes, leading to dirty laundry piling up and causing odors. Certified nurse aides confirmed that laundry was often backed up due to staffing issues, resulting in residents wearing the same clothes for multiple days, which was not dignified and could lead to infection or fall risks. On Unit 4, room conditions included an unsecured alternating pressure mattress machine due to a missing hook and a missing ceiling tile. Despite work requests being submitted, these issues remained unresolved for weeks. Housekeeping staff were responsible for cleaning resident rooms but did not recall any missing or broken ceiling tiles. On Unit 11, observations included broken windowsills, brown matter smeared on walls, sticky floors, and urine odors. Staff interviews revealed that both housekeeping and nursing staff were expected to clean any messes they saw, but there was a lack of clarity on who was responsible for specific tasks. Pest control issues were observed on Units 4 and 10, with fruit flies present in dining areas and resident rooms. Additionally, water/ice machines on Units 8 and 13 were found to have dried white matter, active leaks, and build-up, despite maintenance staff claiming they were cleaned recently. These deficiencies indicate a failure to maintain a safe, clean, and comfortable environment for residents, as required by facility policies and state and federal regulations.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in meeting their medical and nursing needs. Resident #201, who had a history of nicotine dependence, was observed smoking outside the facility grounds multiple times. Despite the facility's tobacco-free policy, no interventions were added to the resident's care plan following these incidents. The resident's care plan lacked specific interventions for nicotine dependence, and there were no documented assessments or sign-out sheets for the resident's off-unit activities, raising concerns about their safety and compliance with facility policies. Resident #62, who had diagnoses including stroke with hemiplegia and chronic obstructive pulmonary disease, was observed multiple times without the necessary pressure reduction booties, positioning pillow, or palm guard as outlined in their care plan. The resident reported that the pressure reduction booties had been removed from their room several months ago and had not been replaced. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan, which could lead to potential skin breakdown and discomfort for the resident. Resident #150, who had diagnoses including diabetes and stroke, was observed out of bed in their wheelchair without the required pressure reducing boots or LNard boots. Despite the care plan and physician orders specifying the use of these boots to prevent pressure ulcers, the resident was seen wearing only nonskid socks. Staff interviews indicated a lack of awareness and adherence to the care plan, with discrepancies between the care plan and the actual care provided. This failure to follow the care plan could result in the resident developing pressure ulcers, which the boots were intended to prevent.
Deficiencies in Personal Care and Hygiene for Residents
Penalty
Summary
The facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, ten residents were observed with various deficiencies in personal care. For example, Resident #62 had unkempt hair, excessive facial hair, and unkept fingernails, while Resident #117 had unkept fingernails. Resident #124 had greasy hair, excessive facial hair, and unkept fingernails, and Resident #150 remained in bed due to mechanical lift battery issues and was poorly positioned for meals. Additionally, Resident #133 was frequently observed poorly positioned in bed for breakfast meals, leading to difficulties in eating and potential aspiration risks. The resident expressed that staff often did not have time to properly position them for meals, which was corroborated by multiple observations and interviews with staff members who acknowledged the issue but did not consistently address it. Resident #215 was not toileted as planned and had excessive facial hair, while Resident #305 was not toileted for over five hours. Resident #325 had greasy hair and was not toileted as planned. Resident #384 and Resident #414 did not receive showers as planned, with Resident #414 also having excessive facial hair. These observations were supported by interviews with the residents and staff, as well as a review of the facility's policies and care plans. For instance, Resident #124, who had diagnoses including epilepsy and contractures of both hands, was observed with greasy hair and long, sharp fingernails despite the care plan indicating they should receive regular grooming and personal hygiene assistance. The resident expressed discomfort due to the lack of grooming, which was not adequately addressed by the staff. Resident #384, who had diagnoses including hemiplegia and diabetes, reported not receiving a scheduled shower and experiencing a strong smell of urine in their room. The resident's call light was not answered for nearly an hour, and there were multiple instances of emesis in the room that were not promptly cleaned. Interviews with staff revealed inconsistencies in providing scheduled showers and addressing residents' hygiene needs. The facility's policies on personal hygiene, meal service, and activities of daily living were not consistently followed, leading to deficiencies in the care provided to the residents.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility did not ensure that residents received food and drink that were palatable, flavorful, and at an appetizing temperature. During the recertification and abbreviated surveys, it was observed that cold food items on test trays were not within the required temperature parameters. Specifically, on two separate occasions, cold food items such as pureed coleslaw, pureed pasta salad, vanilla milkshake, juice, and salad were found to be above the required temperature of 41 degrees Fahrenheit, making them unpalatable. Additionally, a fish sandwich was observed to be dried out and not flavorful. Interviews with residents and staff confirmed the issues with food quality and temperature. One resident stated that lunch and dinner meals did not taste good, while the Director of Food Services and the Director of Clinical Nutrition acknowledged that the cold food items were not within acceptable temperature ranges and were not palatable. The facility's policy on food temperature control and correction was not adhered to, as evidenced by the infrequent test trays and the prolonged meal service time of 2-2.5 hours, which likely contributed to the temperature issues.
Failure to Accommodate Resident's Needs
Penalty
Summary
The facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for a resident with hemiplegia affecting the dominant side. The resident, who was cognitively intact and required substantial assistance with activities of daily living, was unable to use the cold water in their bathroom sink due to the sink's placement and the resident's physical limitations. The bathroom entrance was narrow, making it difficult for the resident to enter using a wheelchair, and the cold water handle was positioned too close to the wall, making it inaccessible for the resident who was paralyzed on the right side. Staff interviews revealed that the resident was recently moved to a new room where they could not use the cold water in the bathroom sink. Both the LPN and CNA confirmed the resident's difficulty in using the bathroom due to the sink's placement and the resident's paralysis. The Unit Manager and the Director of Nursing acknowledged the issue, stating that all residents should have access to both hot and cold water for activities of daily living. An occupational therapist also confirmed the resident's inability to use the right side and the need for accommodations to use the sink effectively.
Failure to Provide Portable Oxygen Leads to Resident Isolation
Penalty
Summary
The facility did not ensure that Resident #429 was free from involuntary seclusion, as the resident reported feelings of social isolation due to not being allowed to leave their room to attend activities, have meals in the dining room, or socialize with peers and family. This was because their portable oxygen tank was empty and was not refilled. The facility's policy on Resident Abuse Reporting prohibited mistreatment, neglect, or abuse, including involuntary seclusion of residents. The policy on Portable Liquid Oxygen System required certified nurse aides to monitor the delivery of oxygen therapy and fill portable cylinders from the base unit when empty. However, this was not consistently done for Resident #429, leading to their isolation in the room. Resident #429, who was admitted with chronic obstructive pulmonary disease and respiratory failure with hypoxia, required oxygen at 4-6 liters via nasal cannula to maintain oxygen levels of 90% or greater. The resident's care plan included the use of a concentrator out of the room and participation in therapeutic activities. Despite this, observations revealed that the resident often had an empty portable oxygen tank and had to stay hooked to the wall oxygen, preventing them from attending morning activities and other engagements. The resident expressed frustration and upset over missing activities and appointments due to the lack of filled portable oxygen tanks. Interviews with staff confirmed that the responsibility of filling portable oxygen tanks was assigned to certified nurse aides on every shift, but this task was not always completed due to short staffing and other reasons. Staff acknowledged that when portable tanks were empty, residents like Resident #429 were confined to their rooms and missed out on activities and appointments. The Director of Nursing stated that all staff were trained on filling portable tanks and expected this to be done every shift, but acknowledged that residents being unable to leave their rooms due to lack of portable oxygen constituted isolation.
Failure to Conduct Annual Performance Reviews for Certified Nurse Aides
Penalty
Summary
The facility failed to ensure that certified nurse aides had their performance reviews completed once every 12 months, as required. Specifically, certified nurse aides #20 and #21, who had been employed for more than 12 months, did not have documented evidence of annual performance evaluations. The facility's policy required supervisors and managers to monitor personnel compliance and conduct annual performance evaluations, but this was not adhered to in these cases. The Administrator confirmed that the evaluations were not completed, and the Unit Managers and Assistant Director of Nursing were identified as responsible for these evaluations. Interviews with various staff members, including the Unit Manager, Assistant Director of Nursing, Director of Nursing, and Chief People Officer, revealed inconsistencies and a lack of clarity regarding the evaluation process. The Unit Manager could not recall the date of the last evaluation for certified nurse aide #20 and had no access to previous evaluations for comparison. Certified nurse aide #20 confirmed they had never received an annual evaluation. The Director of Nursing and Chief People Officer provided conflicting information about the evaluation process and responsibilities, further highlighting the facility's failure to ensure proper performance reviews were conducted and documented as required by regulations.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, Resident #158, who had severe cognitive impairment and behavioral symptoms due to Alzheimer's disease, was not provided with preferred person-centered activities. The resident's care plan included interventions such as listening to specific types of music, engaging in one-to-one activities, and participating in group activities when possible. However, these interventions were not consistently implemented, as evidenced by multiple observations of the resident being left alone in their room with inappropriate music playing or no stimulation at all. The resident's activity records showed minimal engagement in both group and individual activities, despite the care plan's emphasis on these interventions. The resident's family and staff interviews revealed that the resident enjoyed specific types of music and activities, such as blues and jazz music, playing the harmonica, and participating in spiritual programs. However, the resident was often found in their room with new age rap music playing, which they did not like, or with no music or TV on at all. This lack of appropriate stimulation likely contributed to the resident's episodes of yelling and anxious restlessness. Staff interviews indicated a lack of consistent understanding and implementation of the resident's care plan. Certified nurse aides and licensed practical nurses acknowledged that the resident did better in group settings and enjoyed specific types of music, yet the resident was frequently left alone in their room. The social worker and unit manager also noted that the resident should be engaged in activities as much as their behavior allowed, but this was not consistently practiced. The facility's failure to provide appropriate person-centered activities and stimulation for Resident #158 resulted in unmet needs and behavioral symptoms that were not adequately addressed.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility did not ensure each resident was treated with respect and dignity in a manner that promoted maintenance or enhancement of their quality of life for two residents. Resident #384, who was admitted with diagnoses including hemiplegia, obesity, and diabetes, was found in bed with soiled sheets and vomit on their tee shirt. Despite the resident's call bell being activated at 7:30 AM, it was not answered until 8:22 AM. The LPN who responded cleaned the floor but did not clean the resident or change the soiled bed sheets. The resident remained in the soiled bed until 3:13 PM when the sheets were finally changed, but the resident was still not washed up and expressed a desire for a shower. Interviews with staff confirmed that the call bells were often not answered timely and that it was undignified to leave a resident in such a condition. Resident #414, admitted with diagnoses including heart disease and central retinal vein occlusion, was observed multiple times with unshaven stubble, greasy hair, and wearing the same clothes for consecutive days. The resident's room was consistently found with an overflowing bag of dirty clothes, a sticky floor, and a smell of urine. The resident expressed a desire for a shower and clean clothes, stating that their shower day was often moved for staff convenience. Interviews with staff revealed that laundry was picked up only twice a week, leading to a backlog of dirty clothes in the resident's room. The CNA assigned to the resident confirmed that the resident did not refuse care and that the laundry backlog and lack of personal hygiene were undignified. The Director of Nursing stated that call bells should be answered within five minutes and that it was unacceptable for residents to remain in soiled conditions. They also confirmed that laundry backlogs could lead to odors and were not dignified. The facility's failure to promptly address the residents' personal hygiene and environmental cleanliness needs resulted in a lack of dignity and respect for the residents involved.
Failure to Develop and Implement Discharge Plan
Penalty
Summary
The facility failed to ensure the discharge needs of Resident #429 were identified and resulted in the development of a discharge plan. Resident #429, who was admitted with chronic obstructive pulmonary disease, respiratory failure with hypoxia, and diabetes, did not have an active discharge plan despite expressing interest in a lateral transfer to local nursing facilities. The resident was not updated on the status of the lateral transfer request and was not invited to participate in the development of a person-centered care plan. The facility's policies on discharge planning and comprehensive care planning were not followed, as the resident and their family were not included in care plan meetings, and there was no documented evidence of an active discharge plan from August 2023 through February 2024. The social worker's progress notes indicated that a referral for a lateral transfer was made in June 2023, and the resident was placed on a waiting list, but there was no follow-up on the status of the waiting list. The resident's quarterly care conferences did not include the resident or their family, and there was no documentation of a discharge plan. The social worker assigned to the resident was new and unaware of the discharge plan, which contributed to the lack of follow-up and communication with the resident regarding their discharge status. Interviews with the resident and facility staff revealed that the resident had been in the facility for one year and had never been invited to a care plan meeting to discuss their discharge. The resident expressed frustration about not being informed about the status of their lateral transfer request and not being included in care plan meetings. The Director of Social Work acknowledged that follow-up on the discharge plan should have occurred but did not due to the social worker being new. The resident also mentioned that they were told by the facility that they were no longer eligible for a transfer due to insurance reasons, further complicating their discharge planning process.
Inadequate Supervision and Accident Hazards
Penalty
Summary
The facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for two residents. Specifically, one resident was found on the floor between their bed and the wall due to the bed brakes not being locked. The resident had severe cognitive impairment, was totally dependent for bed mobility, and had a history of falls. The incident report and staff statements indicated that the bed was in the lowest position but not locked, leading to the resident falling out of bed. The care plan did not specify the position of the bed or the placement of the fall mat, and there was no documentation to ensure the bed was locked when the resident was in it. The staff involved were re-educated, but the incident was deemed avoidable due to a care plan violation and policy violation regarding the bed brakes not being locked. Another resident with severe dementia and a history of sexually inappropriate behaviors was allowed to propel their wheelchair independently throughout the facility without an adequate supervision plan. The resident had multiple documented incidents of inappropriate touching of other residents and frequently left their unit without notifying staff. The care plan included interventions to not seat the resident near female residents during meals or activities, but these interventions were not consistently followed. Staff interviews revealed that the resident was often off the unit and difficult to track, and there was a lack of communication and monitoring of the resident's behaviors across different units. The resident's care plan interventions were not enforced throughout the facility, leading to inadequate supervision and potential safety risks for other residents. The facility's policies on resident abuse reporting, adverse incident management, and fall risk evaluation were not effectively implemented. The lack of consistent documentation, communication, and adherence to care plan interventions contributed to the deficiencies observed. The facility failed to provide a safe environment and adequate supervision for the residents, resulting in preventable incidents and potential harm.
Inadequate Pain Management for Resident Following Fall
Penalty
Summary
The facility failed to provide adequate pain management for Resident #168 following a fall that resulted in a hip fracture. Despite the resident's complaints of pain in the left hip and knee, there was no documented evidence that the resident's level of pain was evaluated or that pain management was provided from the time of the fall on 12/23/2023 until the resident was sent to the hospital on 12/25/2023. The facility's policy required ongoing pain assessments and management, but this was not adhered to in the case of Resident #168, who had diagnoses including Alzheimer's disease, weakness, and osteoarthritis. Interviews with staff and the resident's family revealed that the resident's pain was not adequately addressed. The family was not properly informed about the resident's condition, and the nurses did not contact the provider for pain medication orders despite the resident's complaints of pain. The Director of Nursing confirmed that the nurses should have called the medical provider to obtain orders for pain medication, but this was not done. The physician also stated that there was no note from a provider that pain medication was requested by nursing.
Deficiency in Nurse Competency and Training
Penalty
Summary
The facility did not ensure that licensed nurses had the specific competencies and skills necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. Specifically, three licensed practical nurses (LPNs) did not have timely online training, annual competencies, or documented orientation competencies completed. LPN Unit Manager #4 had several online trainings completed after their due dates, and both LPN Unit Managers #4 and #33, as well as LPN #34, did not attend the competency/skills fair in 2023. Additionally, LPN Unit Managers #4 and #33 did not have documented competencies from orientation. This lack of training and competency documentation was confirmed through interviews with staff and review of facility records. A resident expressed concerns that nurses did not know how to change their ostomy appliances properly, often using multiple appliances per change, which could lead to wastage. An LPN also stated they had never received education for ostomy or wound care in the facility. Another LPN mentioned that they only signed a paper monthly with in-service topics but did not receive ongoing skill competencies after their initial hire. The Director of Nursing (DON) and other staff confirmed that annual competencies were mandatory and tracked by the education department. The DON stated that nursing staff should be pulled off the schedule if they had not completed their annual competencies. However, the DON was unaware that the three LPNs in question had not completed their required competencies. The facility's policy required all certified nurse aides and licensed nurses to be competency tested annually, but this was not adhered to in these cases.
Failure to Promptly Notify Medical Provider of X-ray Results
Penalty
Summary
The facility did not ensure the medical provider was promptly notified of radiology results for a resident who had fallen and required x-rays. Specifically, the resident had an x-ray ordered for their left knee and hip after a fall, which was completed on the same day. However, the results indicating a minimally displaced fracture of the left femoral neck were not communicated to the medical provider in a timely manner. The results were available in the electronic medical record but were not followed up on by the nursing staff until two days later when the resident's family inquired about the x-ray results. The resident, who had diagnoses including Alzheimer's disease, weakness, and osteoarthritis, experienced a fall after being pushed by another resident. Despite the x-ray being completed and the results being available, the nursing staff did not notify the medical provider or follow up on the results promptly. The delay in communication resulted in the resident experiencing pain and the family being unaware of the severity of the injury until they visited the resident and inquired about the x-ray results. Interviews with the nursing staff and the Director of Nursing revealed that there was an expectation for nurses to follow up on x-ray results within 30 to 45 minutes after the x-ray was completed. However, there was no specific policy in place to ensure this follow-up occurred. The failure to promptly notify the medical provider of the x-ray results led to a delay in the resident receiving appropriate medical attention for their hip fracture.
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 216 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — 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 Syracuse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Iroquois Nursing Home Inc | 1.3 mi | ★★★★★ | 1 | 0 |
| Central Park Rehabilitation And Nursing Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Van Duyn Center For Rehabilitation And Nursing | 1.8 mi | — | 54 | 6 |
| Upstate University Hosp At Community General T C U | 1.9 mi | ★★★★★ | 0 | 0 |
| Nottingham R H C F | 2.2 mi | ★★★★★ | 7 | 0 |
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