Inspection Reports for
Loretto Health and Rehabilitation Center
700 E Brighton Ave, Syracuse, NY 13205, USA, NY, 13205
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
28.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
459% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 19
Date: Aug 29, 2025
Visit Reason
Complaint survey with 13 health and 6 life safety deficiencies, mostly Level 2 severity, no actual harm but potential for minor discomfort. Deficiencies include activities of daily living, food sanitation, infection control, and multiple life safety code issues.
Findings
Complaint survey with 13 health and 6 life safety deficiencies, mostly Level 2 severity, no actual harm but potential for minor discomfort. Deficiencies include activities of daily living, food sanitation, infection control, and multiple life safety code issues.
Deficiencies (19)
Activities daily living (adls)/mntn abilities — quality of care
Activities meet interest/needs each resident — quality of care
Dialysis — quality of care
Food procurement,store/prepare/serve-sanitary — quality of care
Free of accident hazards/supervision/devices — quality of care
Infection prevention & control — quality of care
Investigate/prevent/correct alleged violation — quality of care
Label/store drugs and biologicals — quality of care
Maintains effective pest control program — quality of care
Nutritive value/appear, palatable/prefer temp — quality of care
Pain management — quality of care
Respiratory/tracheostomy care and suctioning — quality of care
Safe/clean/comfortable/homelike environment — quality of care
Electrical equipment - power cords and extens — life safety
Gas and vacuum piped systems - information an — life safety
Hazardous areas - enclosure — life safety
Means of egress - general — life safety
Sprinkler system - maintenance and testing — life safety
Utilities - gas and electric — life safety
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Aug 29, 2025
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 8/25/2025 to 8/29/2025 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, and homelike environment; inadequate investigation and reporting of injuries of unknown origin; lack of appropriate translation services; insufficient activity programming; unsafe mechanical lift transfers; improper respiratory care; inadequate pain management; incomplete dialysis assessments; improper medication storage and labeling; food served at inappropriate temperatures; unsanitary kitchen conditions; failure to implement infection control precautions; and ineffective pest control program.
Deficiencies (13)
F 0584: The facility failed to ensure a safe, clean, and homelike environment for four of fourteen resident units, including soiled linens on floors, stained ceiling tiles, unclean privacy curtains, and dirty wheelchairs.
F 0610: The facility did not thoroughly investigate and report injuries of unknown origin for one resident, failing to notify the state within 24 hours as required.
F 0676: The facility did not provide appropriate treatment and services to maintain or improve activities of daily living, including failure to provide translation services for a resident with limited English proficiency.
F 0679: The facility did not provide meaningful activities consistent with resident interests and preferences for one resident, including failure to offer activities during staff absence.
F 0689: The facility failed to ensure adequate supervision and safe use of mechanical lifts, transferring residents requiring two-person assistance with only one staff member.
F 0695: The facility did not provide safe and appropriate respiratory care for one resident, including failure to clean bilevel positive airway pressure mask as ordered, resulting in brown debris in the mask.
F 0697: The facility failed to provide safe, appropriate pain management for one resident, including failure to apply prescribed pain patch as ordered and lack of documentation of pain treatment effectiveness.
F 0698: The facility did not provide safe, appropriate dialysis care for two residents, including failure to complete pre- and post-dialysis assessments as ordered and incomplete documentation.
F 0761: The facility failed to ensure drugs and biologicals were stored and labeled according to professional standards, including unlocked medication and treatment carts, expired and undated medications, and unlocked medication cart screens.
F 0804: The facility did not ensure food was served at palatable and appetizing temperatures, with test trays showing bland taste and improper temperatures, and residents reporting cold and overcooked food.
F 0812: The facility failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including expired foods, out-of-range refrigerator temperatures, and unclean kitchen areas with standing water and food debris.
F 0880: The facility failed to implement an effective infection prevention and control program, including staff not wearing required gowns and gloves during enhanced barrier precautions for one resident.
F 0925: The facility did not maintain an effective pest control program, with persistent fruit flies observed in multiple kitchens and resident areas despite vendor treatments.
Report Facts
Resident units reviewed: 14
Residents reviewed: 8
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 3
Residents reviewed: 3
Medication carts reviewed: 13
Treatment carts reviewed: 14
Medication storage rooms reviewed: 7
Kitchen and kitchenettes reviewed: 18
Days with out-of-range refrigerator temperatures: 23
Fruit fly sightings: 15
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 29, 2025
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory standards for resident care, environment, and food service.
Findings
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents, including issues with soiled linens, stained ceiling tiles, unclean privacy curtains, and dirty wheelchairs. Additionally, food was found to be served at unpalatable temperatures and was often cold, overcooked, and bland according to resident complaints and test tray observations.
Deficiencies (2)
F 0584: The facility did not maintain a safe, clean, and homelike environment for four of fourteen resident units reviewed, including soiled linens on the floor, stained ceiling tiles, unclean privacy curtains, and dirty wheelchairs.
F 0804: The facility did not ensure food was served at palatable, attractive, and safe temperatures for nine residents and two test trays reviewed, with complaints of cold, overcooked, and bland food.
Report Facts
Resident units reviewed: 14
Resident units with deficiencies: 4
Residents affected: 9
Test trays reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #43 | Provided care for Resident #63 and described linen handling | |
| Licensed Practical Nurse #42 | Commented on infection control issues with linens on floor | |
| Licensed Practical Nurse Assistant Nurse Manager #41 | Stated proper disposal of soiled linens and briefs | |
| Registered Nurse Unit Manager #48 | Stated soiled briefs and linens should not be left on floor | |
| Housekeeping Crew Leader #58 | Described privacy curtain cleaning and replacement process | |
| Housekeeper #60 | Responsible for cleaning resident wheelchairs | |
| Certified Nurse Aide #61 | Described wheelchair cleaning responsibilities | |
| Licensed Practical Nurse #47 | Stated staff should wipe down dirty chairs | |
| Director of Maintenance | Described ceiling tile repairs and window shade replacement | |
| Director of Housekeeping | Described cleaning checklists and wheelchair cleaning schedule | |
| Licensed Practical Nurse #8 | Reported resident complaints about food quality | |
| Certified Nurse Aide #28 | Reported resident complaints about food temperature and quality | |
| Registered Nurse Manager #4 | Received frequent resident complaints about food | |
| Dietary Aide #29 | Prepared resident foods and described food temperature standards | |
| Food Service Supervisor #30 | Described tray audits and food temperature monitoring | |
| Commissary Director #14 | Described food preparation, cooking, and plating process | |
| Senior Director of Operations | Commented on resident lounge condition and repair process |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 30
Date: Apr 23, 2024
Visit Reason
Complaint survey with 18 health and 12 life safety deficiencies, all Level 2 severity, many corrected as of June 21, 2024. Deficiencies include ADL care, competent nursing staff, care planning, food sanitation, resident rights, and multiple life safety code issues.
Findings
Complaint survey with 18 health and 12 life safety deficiencies, all Level 2 severity, many corrected as of June 21, 2024. Deficiencies include ADL care, competent nursing staff, care planning, food sanitation, resident rights, and multiple life safety code issues.
Deficiencies (30)
ADL care provided for dependent residents — quality of care
Competent nursing staff — quality of care
Develop/implement comprehensive care plan — quality of care
Discharge planning process — quality of care
Food procurement,store/prepare/serve-sanitary — quality of care
Free from involuntary seclusion — quality of care
Free of accident hazards/supervision/devices — quality of care
Grievances — quality of care
Label/store drugs and biologicals — quality of care
Nurse aide peform review-12 hr/yr in-service — quality of care
Nutritive value/appear, palatable/prefer temp — quality of care
Pain management — quality of care
Personal privacy/confidentiality of records — quality of care
Radiology/diag srvcs ordered/notify results — quality of care
Reasonable accommodations needs/preferences — quality of care
Resident rights/exercise of rights — quality of care
Safe/clean/comfortable/homelike environment — quality of care
Treatment/service for dementia — quality of care
Building construction type and height — life safety
Doors with self-closing devices — life safety
Egress doors — life safety
Electrical equipment - power cords and extens — life safety
Electrical equipment - testing and maintenanc — life safety
Electrical systems - essential electric syste — life safety
Fire alarm system - testing and maintenance — life safety
Hazardous areas - enclosure — life safety
Sprinkler system - installation — life safety
Sprinkler system - maintenance and testing — life safety
Subdivision of building spaces - smoke barrie — life safety
Subsistence needs for staff and patients — life safety
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Apr 23, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 4/15/2024 to 4/23/2024 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, accommodation of resident needs, privacy violations, environmental cleanliness, grievance process, involuntary seclusion, care planning, activities of daily living assistance, supervision, pain management, medication labeling and storage, food safety, staff competencies, and dementia care.
Deficiencies (16)
F 0550: The facility failed to ensure residents were treated with dignity and respect, as evidenced by residents sitting in soiled bedding and unkempt personal hygiene.
F 0558: The facility did not reasonably accommodate resident needs and preferences, such as providing accessible bathroom sinks for residents with hemiplegia.
F 0583: The facility failed to protect residents' personal and medical records privacy, posting identifiable information in public areas visible to others.
F 0584: The facility did not ensure a safe, clean, comfortable, and homelike environment, with issues including dirty rooms, sticky floors, pest infestations, and unclean resident-use equipment.
F 0585: The facility did not provide adequate information or access to file anonymous grievances, as residents were unaware of grievance procedures and officers.
F 0603: The facility failed to prevent involuntary seclusion by restricting a resident's movement due to unfilled portable oxygen tanks, limiting their participation in activities and socialization.
F 0656: The facility did not develop and implement comprehensive person-centered care plans for residents, including failure to address smoking privileges, pressure injury prevention devices, and discharge planning.
F 0677: The facility failed to provide necessary assistance for activities of daily living, resulting in poor nutrition, grooming, hygiene, and positioning for multiple residents.
F 0689: The facility did not ensure adequate supervision and accident hazard prevention for residents at risk of falls or with behavioral issues, including failure to lock bed brakes and monitor wandering residents.
F 0697: The facility failed to provide adequate pain management for a resident following a fall with a hip fracture, including failure to evaluate pain and obtain pain medication orders.
F 0726: The facility did not ensure licensed nurses completed required annual competencies and orientation documentation timely.
F 0730: The facility did not complete annual performance reviews for certified nurse aides as required.
F 0744: The facility failed to provide appropriate treatment and services to a resident with dementia, including failure to provide preferred person-centered activities and adequate socialization.
F 0761: The facility did not ensure drugs and biologicals were labeled and stored according to professional standards, including unlabeled nicotine patches, expired medications, unlabeled insulin and inhalers, and unclean medication refrigerators.
F 0777: The facility did not promptly notify the medical provider of radiology results for a resident with a hip fracture, delaying appropriate pain management and treatment.
F 0804: The facility did not ensure food and drink were palatable, flavorful, and served at safe and appetizing temperatures, with cold foods served above safe temperature limits.
Report Facts
Deficiencies cited: 16
Fall Risk Evaluation score: 24
Food temperature: 65
Food temperature: 59
Food temperature: 54
Food temperature: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #43 | Named in dignity and respect deficiency related to Resident #384 not being cleaned timely after vomiting | |
| Certified Nurse Aide #44 | Named in dignity and respect deficiency related to Resident #384 care | |
| Registered Nurse Unit Manager #14 | Named in dignity and respect deficiency and shower care refusals | |
| Director of Nursing | Named in multiple interviews regarding dignity, laundry, grievance process, oxygen tank issues, and fall prevention | |
| Certified Nurse Aide #8 | Named in dignity and respect deficiency and shower care refusals | |
| Licensed Practical Nurse Unit Manager #4 | Named in oxygen tank deficiency and shower care refusals | |
| Certified Nurse Aide #77 | Named in smoking and care plan deficiency for Resident #201 | |
| Registered Nurse Unit Manager #27 | Named in privacy violation and behavioral supervision deficiencies | |
| Social Worker #29 | Named in discharge planning and behavioral supervision deficiencies | |
| Licensed Practical Nurse #46 | Named in pain management and medication labeling deficiencies | |
| Licensed Practical Nurse #48 | Named in pain management and medication labeling deficiencies | |
| Licensed Practical Nurse Unit Manager #40 | Named in fall prevention deficiency | |
| Certified Nurse Aide #38 | Named in fall prevention deficiency related to bed brakes not locked | |
| Licensed Practical Nurse Unit Manager #33 | Named in staff competency deficiency | |
| Licensed Practical Nurse #24 | Named in staff competency deficiency | |
| Certified Nurse Aide #63 | Named in activities of daily living deficiency | |
| Licensed Practical Nurse #67 | Named in activities of daily living deficiency | |
| Registered Nurse Unit Manager #66 | Named in activities of daily living deficiency | |
| Licensed Practical Nurse #6 | Named in medication labeling deficiency | |
| Registered Nurse Unit Manager #27 | Named in medication cart and food storage deficiencies | |
| Licensed Practical Nurse #73 | Named in medication labeling deficiency | |
| Licensed Practical Nurse #74 | Named in medication labeling deficiency | |
| Licensed Practical Nurse #13 | Named in medication refrigerator deficiency | |
| Assistant Director of Nursing #23 | Named in medication labeling deficiency | |
| Licensed Practical Nurse #45 | Named in pain management deficiency | |
| Licensed Practical Nurse #52 | Named in pain management deficiency | |
| Physician #53 | Named in pain management deficiency | |
| Licensed Practical Nurse #20 | Named in certified nurse aide performance review deficiency | |
| Registered Nurse Unit Manager #28 | Named in certified nurse aide performance review deficiency | |
| Certified Nurse Aide #70 | Named in dementia care deficiency | |
| Licensed Practical Nurse #46 | Named in dementia care deficiency | |
| Licensed Practical Nurse Unit Manager #52 | Named in pain management and dementia care deficiency | |
| Certified Nurse Aide #30 | Named in behavioral supervision deficiency | |
| Licensed Practical Nurse #31 | Named in behavioral supervision deficiency | |
| Registered Nurse Unit Manager #40 | Named in fall prevention deficiency | |
| Certified Nurse Aide #38 | Named in fall prevention deficiency | |
| Licensed Practical Nurse #39 | Named in fall prevention deficiency | |
| Director of Staff Education and Development | Named in staff competency deficiency | |
| Licensed Practical Nurse Assistant Unit Manager #33 | Named in fall prevention and staff competency deficiency | |
| Certified Nurse Aide #21 | Named in certified nurse aide performance review deficiency | |
| Director of Human Resources | Chief People Officer | Named in certified nurse aide performance review deficiency |
| Director of Food Services #57 | Named in food temperature deficiency | |
| Diet Technician #58 | Named in food temperature deficiency | |
| Food Service Supervisor | Named in food temperature deficiency |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Apr 23, 2024
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 4/15/2024 to 4/23/2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, safe and homelike environment, comprehensive care planning, discharge planning, activities of daily living assistance, accident hazard prevention, pain management, nurse competencies, timely communication of x-ray results, and food safety related to temperature and palatability.
Deficiencies (10)
F 0550: The facility failed to ensure residents were treated with dignity and respect, as evidenced by residents sitting in soiled bed sheets and unkempt personal hygiene.
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment, with issues such as overflowing laundry, sticky floors, missing ceiling tiles, pest infestation, and unclean resident equipment.
F 0656: The facility failed to develop and implement comprehensive person-centered care plans meeting residents' medical and nursing needs, including lack of plans for smoking, positioning devices, and outside privileges.
F 0660: The facility did not ensure discharge needs were identified and discharge plans developed, as Resident #429 was not updated on lateral transfer status and was not invited to care plan meetings.
F 0677: The facility failed to provide necessary assistance with activities of daily living, resulting in poor nutrition, grooming, and hygiene for multiple residents.
F 0689: The facility did not ensure adequate supervision and accident hazard prevention, including failure to lock bed brakes leading to a resident fall and inadequate supervision of a resident with sexually inappropriate behaviors.
F 0697: The facility failed to provide appropriate pain management for Resident #168 following a fall with a hip fracture, with no documented pain evaluation or pain medication provided.
F 0726: Licensed nurses lacked timely completion of required annual competencies and orientation skills, including Unit Managers and licensed practical nurses.
F 0777: The facility did not promptly notify the medical provider of radiology results for Resident #168, delaying awareness of a hip fracture diagnosis.
F 0804: The facility failed to ensure food and drink were palatable, flavorful, and served at safe and appetizing temperatures, with cold food items served above safe temperature limits.
Report Facts
Fall Risk Evaluation score: 24
Temperature of cold food items: 53
Temperature of cold food items: 65
Temperature of cold food items: 59
Temperature of cold food items: 54
Temperature of cold food items: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #43 | Named in observation of Resident #384 not being cleaned timely after vomiting. | |
| Certified Nurse Aide #44 | Provided statements about Resident #384's condition and call bell response. | |
| Registered Nurse Unit Manager #14 | Provided statements on expectations for call bell response and resident care. | |
| Director of Nursing | Provided statements on call bell expectations, dignity concerns, and care plan compliance. | |
| Certified Nurse Aide #8 | Provided statements about Resident #414's hygiene and laundry issues. | |
| Licensed Practical Nurse Unit Manager #4 | Provided statements on laundry pickup and care plan compliance. | |
| Maintenance Worker #83 | Provided statements on cleaning of ice machines. | |
| Certified Nurse Aide #5 | Reported on dirty linen left on floor and potential infection risk. | |
| Certified Nurse Aide #30 | Provided statements on resident care instructions and meal positioning. | |
| Certified Nurse Aide #64 | Provided statements on resident care instructions and meal positioning. | |
| Licensed Practical Nurse Unit Manager #40 | Involved in re-education after resident fall due to unlocked bed brakes. | |
| Certified Nurse Aide #38 | Involved in incident where resident fell due to bed brakes not locked. | |
| Licensed Practical Nurse #48 | Provided progress notes related to Resident #168's fall and hospital transfer. | |
| Licensed Practical Nurse Unit Manager #52 | Covering nurse manager during Resident #168's fall incident. | |
| Physician #53 | Provided statements on pain management and x-ray result notification. | |
| Director of Nursing | Provided statements on pain management expectations and x-ray follow-up. | |
| Director of Food Services #57 | Provided statements on food temperature standards and meal service. | |
| Diet Technician #58 | Provided statements on test trays and food temperature importance. | |
| Licensed Practical Nurse Unit Manager #33 | Named in relation to missing competencies. | |
| Licensed Practical Nurse #34 | Named in relation to missing competencies. | |
| Licensed Practical Nurse Nurse Educator #26 | Provided statements on competency testing and skills fair. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jun 22, 2023
Visit Reason
Complaint survey with 2 health deficiencies, both Level 2 severity, corrected as of August 21, 2023. Deficiencies related to accident hazards and investigation of alleged violations.
Findings
Complaint survey with 2 health deficiencies, both Level 2 severity, corrected as of August 21, 2023. Deficiencies related to accident hazards and investigation of alleged violations.
Deficiencies (2)
Free of accident hazards/supervision/devices — quality of care
Investigate/prevent/correct alleged violation — quality of care
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 22, 2023
Visit Reason
The abbreviated survey was conducted to investigate alleged violations related to Resident #2 sustaining skin tears of unknown origin and to assess compliance with supervision and investigation policies.
Findings
The facility failed to thoroughly investigate alleged violations for Resident #2 who sustained multiple skin tears of unknown origin. The resident was placed on one-to-one supervision but was not provided direct supervision as ordered, resulting in a skin tear. The investigation did not address whether supervision was provided as ordered and did not rule out abuse or neglect.
Deficiencies (2)
F 0610: The facility did not ensure all alleged violations were thoroughly investigated for Resident #2 who sustained skin tears of unknown origin. The investigation did not address the resident's order for one-to-one supervision or whether it was provided as ordered.
F 0689: The facility did not ensure adequate supervision to prevent accidents for Resident #2 placed on one-to-one direct supervision. The resident was not provided direct supervision and sustained a skin tear of unknown origin.
Report Facts
Falls: 12
Skin tears: 2
ISM shifts signed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Assigned to provide one-to-one supervision (ISM) for Resident #2 on 10/23/2022; stated they did not provide care due to staffing issues and could not recall providing ISM at the time of the skin tear. |
| RN Manager #8 | Registered Nurse Manager | Completed the Incident Accident Investigation on 10/28/2022 and conducted interviews related to Resident #2's skin tear and supervision. |
| RNS #5 | Registered Nurse Supervisor | Notified the on-call provider of Resident #2's skin tear on 9/6/2022 and was responsible for initiating investigation. |
| RNS #6 | Registered Nurse Supervisor | Responded to the skin tear incident on 10/23/2022 and documented no reasonable cause to suspect abuse or neglect. |
| Administrator | Administrator | Interviewed on 6/22/2023 regarding ISM policy and supervision of Resident #2. |
| Director of Nursing | Director of Nursing (DON) | Interviewed on 6/22/2023 regarding ISM policy and supervision of Resident #2. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 12
Date: Sep 23, 2022
Visit Reason
Complaint survey with 7 health and 5 life safety deficiencies, all Level 2 severity, corrected as of November 18, 2022. Deficiencies included ADL care, care planning, accident hazards, nutritive value, resident rights, medication errors, and multiple life safety code issues.
Findings
Complaint survey with 7 health and 5 life safety deficiencies, all Level 2 severity, corrected as of November 18, 2022. Deficiencies included ADL care, care planning, accident hazards, nutritive value, resident rights, medication errors, and multiple life safety code issues.
Deficiencies (12)
ADL care provided for dependent residents — quality of care
Develop/implement comprehensive care plan — quality of care
Free of accident hazards/supervision/devices — quality of care
Nutritive value/appear, palatable/prefer temp — quality of care
Resident rights/exercise of rights — quality of care
Residents are free of significant med errors — quality of care
Safe/clean/comfortable/homelike environment — quality of care
Electrical equipment - power cords and extens — life safety
Electrical systems - essential electric syste — life safety
Fire alarm system - installation — life safety
Hazardous areas - enclosure — life safety
Sprinkler system - installation — life safety
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Sep 23, 2022
Visit Reason
The survey was a recertification survey conducted from 9/19/22 to 9/23/22 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including residents' dignity and privacy, environmental cleanliness and maintenance, care planning and implementation, assistance with activities of daily living, supervision to prevent accidents, medication administration errors, and food safety and palatability.
Deficiencies (7)
F 0550: The facility failed to ensure residents' right to a dignified existence for 1 of 4 residents reviewed; Resident #127's urinary catheter drainage bag was uncovered and visible in multiple locations.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment for 3 residents and multiple units due to unclean furniture, damaged walls, stained ceilings, loose windowsills, and presence of fruit flies.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #264, who was care planned for total dependence on 2 staff for transfers but was transferred by 1.
F 0677: The facility failed to ensure residents unable to perform activities of daily living received necessary assistance; Residents #8, 238, 264, and 386 had deficiencies in oral care, clothing changes, toileting, meal assistance, and hygiene.
F 0689: The facility failed to provide adequate supervision to prevent accidents for Resident #171, who was on aspiration precautions but was observed eating unsupervised in their room with the door closed.
F 0760: The facility failed to ensure residents were free from significant medication errors; Residents #33 and #368 did not receive blood glucose monitoring or insulin administration as ordered due to missed diabetic tab documentation and lack of staff training.
F 0804: The facility failed to ensure food was palatable, attractive, and at a safe temperature; Resident #355's replacement meal was reheated without measuring internal temperature to confirm safety.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #40 | Certified Nursing Assistant | Named in oral care deficiency for Resident #8 |
| RN Unit Manager #9 | Registered Nurse Unit Manager | Named in care plan and medication administration deficiencies |
| LPN #41 | Licensed Practical Nurse | Named in care plan and supervision deficiencies |
| CNA #45 | Certified Nursing Assistant | Named in supervision and toileting deficiencies for Resident #264 |
| NP #22 | Nurse Practitioner | Named in medication error follow-up |
| SLP #47 | Speech Language Pathologist | Named in aspiration precautions deficiency for Resident #171 |
| Food Service Director | Named in food temperature deficiency | |
| Administrator | Named in food temperature deficiency |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 1, 2022
Visit Reason
Complaint survey with 1 health deficiency of Level 0 severity related to responsibilities of providers and required notifications.
Findings
Complaint survey with 1 health deficiency of Level 0 severity related to responsibilities of providers and required notifications.
Deficiencies (1)
Responsibilities of providers; required notif — quality of care
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