Loretto Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review during the abbreviated survey (2711290) conducted on 03/10/2026, the facility did not ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of four (4) residents reviewed (Resident #2). Specifically, for Resident #2:- The 11/28/2025 Hospital Discharge Summary documented several pressure ulcers and recommended treatments. There was no documented evidence that the resident's skin was assessed upon admission and treatment orders were not obtained timely. - On 12/05/2025, nursing noted eight unstageable pressure ulcers (base of wound obscured by non-viable tissue; [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00367212/446001) surveys conducted 8/25/2025-8/29/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for four (4) of fourteen (14) resident units ([NAME] Units 4, 5, 7, and 13) reviewed. Specifically, Resident #63 had dirty linens, and a soiled brief left at their bedside; Resident #187's room had a ceiling tile with a large brown stain and an unclean privacy curtain; Resident #314's room had a ceiling tile with a medium black stain; Resident #21's window shade had several brown spots; and Resident #373's wheelchair was unclean.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/25/2025 - 8/29/2025, the facility did not ensure the resident environment remained free of accident hazards for three (3) of three (3) residents (Residents #5, #63, and #510) reviewed. Specifically, Residents #5, #63, and #510 were transferred via a mechanical lift with assistance of one and not assistance of two as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for four (4) of thirteen (13) medication carts (4th floor cart [NAME] building, and 5th, 7th,and 6th floor [NAME] carts), two (2) of fourteen (14) treatment carts (2nd and 4th floor [NAME] carts) and one (1) of seven (7) medication storage rooms (5th floor [NAME] medication room). Specifically, the 5th and 7th floor [NAME] medication cart had undated and expired medications and biologicals; the 6th floor [NAME] medication cart was left unattended and unlocked; the 2nd and 4th floor [NAME] treatment carts were unlocked; and the 5th floor [NAME] medication room had expired medication.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY002586082/iQIES 446001) surveys conducted 8/25/2025-8/29/2025, the facility did not ensure food was served at palatable and appetizing temperatures in accordance with professional standards for food service for 9 anonymous residents and 2 of 2 test trays (8/27/2025 and 8/28/2025 lunch meals) reviewed. Specifically, the lunch meal test trays on 8/27/2025 and 8/28/2025 were not flavorful or served at palatable and appetizing temperatures; and 9 anonymous residents at the Resident Council Meeting stated the food was often cold, not flavorful, and overcooked.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for two (2) of two (2) kitchens (basement and second floor main kitchens), and four (4) of fourteen (14) kitchenettes ([NAME] 13, [NAME] 2, 3, and 4 kitchenettes) reviewed. Specifically, the basement and second floor kitchens had unclean areas, standing water, and appliances in disrepair; [NAME] 3 kitchenette had expired food; [NAME] 2 kitchenette had expired food and undated foods; [NAME] 4 kitchenette had expired food; and [NAME] 13 kitchenette had out of range refrigerator temperature and food, and incomplete temperature logs.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not maintain an effective pest control program so that the facility was free of pests for seven areas (the basement and 2nd floor kitchen, and [NAME] units 3, 5, 6, 8, and 10. Specifically, pest control was not maintained for fruit flies in the basement and 2nd floor kitchen, and [NAME] units 3, 5, 6, 8, and 10.

Inspectors wroteBased on record review and interviews during the recertification and abbreviated (NY00375455/iQIES 446000) surveys conducted 8/25/2025-8/29/2025 the facility did not ensure allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated to prevent further potential abuse and mistreatment for one (1) of eight (8) residents (Resident #50) reviewed. Specifically, Resident #50 sustained injuries of unknown origin with unexplained bruising to the head, shoulder, and upper chest that was not thoroughly investigated to rule out abuse or mistreatment. Additionally, the resident's injuries of unknown origin were not reported to the New York State Department of Health within 24 hours as required.

Inspectors wroteBased on observations, record review, and interview during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure residents were provided the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living including functional communication systems for one (1) of one (1) resident (Resident #63) reviewed. Specifically, Resident #63's primary language was not English, and they were not provided with translation services.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not provide ongoing programs to support each resident in their choice of activities for one (1) of one (1) resident (Resident #10) reviewed. Specifically, Resident #10 was not offered meaningful activities that included their interests and preferences.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (1) of three (3) residents (Resident #546) reviewed. Specifically, Resident #546's bilevel positive airway pressure machine (a noninvasive ventilator that helps with breathing) was not cleaned as ordered and had brown debris in the mask. Findings Include: The facility policy Bilevel positive airway pressure, Continuous positive airway pressure Trilogy, effective 2/2020 documented non-invasive ventilator support was provided to patients with compromised airways or chronic pulmonary/cardiac diseases. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure pain management was provided to residents who required such services consistent with professional standards of practice for one (1) of one (1) resident (Residents #21) reviewed. Specifically, Resident #21 did not have their prescribed pain patch placed as ordered and they did not have the effectiveness of their pain treatment documented.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure that residents who required dialysis (treatment to filter waste products from the blood when the kidneys do not work) received such services consistent with professional standards of practice for two (2) of two (2) residents (Residents #7 and #336) reviewed. Specifically, Residents #7 and #336 did not have pre-and post-dialysis assessments as ordered.

Inspectors wroteBased on observations, interviews, and record review during the recertification survey conducted 8/25/2025-8/29/2025, the facility did 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 (1) of five (5) residents (Resident #282) reviewed. Specifically, Resident #282 was on enhanced barrier precautions and Certified Nurse Aides #56 and #57 did not wear proper personal protective equipment while performing care.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/15/2024-4/23/2024 the facility did not ensure resident rights to personal privacy and confidentiality of their personal and medical records for 8 of 8 residents (Residents #1, #10, #133, #158, #305, #323, #325, and #397) reviewed. Specifically, Residents #1, #10, #133, #158, #305, #323, #325, and #397 identifying and personal information was posted in a public area visible to others.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00321560, NY00336003, NY00320334, NY00318518, NY00315691 and NY00330793) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 6 of 14 resident units ([NAME] Units 3, 4, 8, 10, 11, and 13) reviewed. Specifically: - on [NAME] Unit 3, room [ROOM NUMBER]-W had overflowing laundry bags, the bathroom was visibly dirty and had a strong urine odor, and the room floors were sticky. - on [NAME] Unit 4, room [ROOM NUMBER]-W's alternating pressure mattress machine had a missing right hook to secure the machine, and a ceiling tile was missing. - [NAME] Unit 11 had sticky floors; room [ROOM NUMBER]-W had a dirty wall, and liquid and debris on the floor; and room [ROOM NUMBER]-W had a broken stone windowsill. [...]

Inspectors wroteBased on record review, observation, and interviews during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure information on filing grievances was available for 11 of 11 anonymous residents present at the Resident Council meeting. Specifically, 11 anonymous residents present at the Resident Council meeting stated they did not know how to file an anonymous grievance.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00315691, NY00318518, NY00320334, NY00321560, NY00329469, NY00330471, NY00331762, and NY00332641) surveys conducted 4/15/2024 through 4/23/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet the residents medical and nursing needs for 3 of 4 residents (Residents #62, #150 and #201) reviewed. Specifically, Resident #201 did not have a comprehensive care plan developed to include outside privileges or smoking outside on facility grounds; Resident #62 did not have a positioning pillow, palm guard, or pressure reduction boots as planned; and Resident #150 was not wearing their pressure reducing heel boots as planned.

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated surveys (NY00315691, NY00318518, NY00321560, NY00329469, NY00330555, NY00332641, NY00334153, NY00336003, and NY00338231) conducted 4/19/2024-4/23/2024, the facility did not ensure 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 for 10 of 13 residents (Residents #62, 117, 124, 133, 150, 215, 305, 325, 384, and 414) reviewed. Specifically: - Resident #62 had unkempt hair, excessive facial hair, and unkept fingernails; - Resident #117 had unkept fingernails; - Resident #124 had unkept fingernails, greasy hair, and excessive facial hair; - Resident #150 remained in bed due to mechanical lift battery issues and was poorly positioned for meals; [...]

Inspectors wroteBased on observation and interview during the recertification survey conducted 4/23/2023 -4/23/2024, the facility did not ensure drugs and biologicals were labelled and stored in accordance with currently accepted professional principles for 5 of 12 medication carts ([NAME] units 3, 4, 8, 10, and 14) reviewed, and 1 of 6 medication rooms ([NAME] unit 5) reviewed. Specifically, the medication cart on [NAME] unit 3 had nicotine patches without resident labels; [NAME] unit 4 had expired medications; [NAME] unit 8 has insulin without a labeled open date; [NAME] unit 10 had inhalers not in the correct pharmacy box and without labeled open dates and unlabeled eye medications; [NAME] unit 13 had personal food items stored with resident medications; and [NAME] 5 medication room had a refrigerator with a significant amount of ice buildup.

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00330555) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 3 test trays reviewed (4/16/2024 and 4/18/2024 lunch meals). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 4 of 14 food preparation and pantry storage areas ([NAME] Unit 4, and [NAME] Units 4, 5, 6) and in the main kitchen. Specifically, the pantry storage areas on [NAME] Unit 4, and [NAME] Units 4, 5, 6 were soiled with food spills and the refrigerators were not cleaned of food debris and spills. Additionally, the main kitchen tray line had cold food tables with food items temperatures ranging from 40- 55 degrees Fahrenheit.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00321560, NY00315691, and NY00336003) surveys conducted 4/15/2024-4/23/2024, 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 2 of 5 residents (Residents #384 and #414) reviewed. Specifically, Resident #384 sat in bed sheets soiled with vomit and was not cleaned in a timely manner and Resident #414 was not shaven, had unkept hair, and had an unclean room.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/15/2024-4/23/2023, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 1 of 2 resident (Resident #31) reviewed. Specifically, Resident #31 was not able to use their bathroom sink to effectively perform activities of daily living.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure residents were free from involuntary seclusion for 1 of 1 resident (Resident #429) reviewed. Specifically, Resident #429 reported feelings of social isolation when they were not allowed to leave their room to attend activities, have meals in the dining room, or socialize with peers and family because their portable oxygen tank was empty and was not refilled.

Inspectors wroteBased on interview and record review during the recertification and abbreviated (NY00320334) surveys conducted 4/15/2024-4/23/2023, the facility did not ensure the discharge needs of each resident were identified and resulted in the development of a discharge plan for 1 of 1 resident (Resident #429) reviewed. Specifically, Resident #429 did not have an active discharge plan, expressed interest in a lateral transfer to local nursing facilities, and was not updated on the status of a lateral transfer request. Additionally, Resident #429 was not invited to participate in the development of a person-centered care plan.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated surveys (NY00318518, NY00318847, NY00320334, NY00331963, and NY00338231) the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for 2 of 9 residents (Residents #117 and #323) reviewed. Specifically, Resident #117 was found on the floor between their bed and the wall due to the bed brakes not being locked; and Resident #323 had a history of sexually inappropriate behaviors and propelled their wheelchair independently throughout the facility without an adequate supervision plan.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00329469, NY00331762, NY00330471) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure pain management was provided to residents who required such services consistent with professional standards of practice for 1 of 2 residents (Resident #168) reviewed. Specifically, Resident #168 did not receive adequate pain management following a fall with a hip fracture.

Inspectors wroteBased on record review and interview during the recertification and abbreviated (NY00336003) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure licensed nurses had the specific competencies and skills necessary to care for residents' need, as identified through resident assessments, and described in the plan of care for 3 of 5 licensed nurses (licensed practical nurse Unit Manager #4, licensed practical nurse Unit Manager #33, and licensed practical nurse #34) reviewed. Specifically, licensed practical nurse Unit Manager #4 did not have timely online training, annual competencies, or documented orientation competencies completed; licensed practical nurse Unit Manager #33 did not have annual competencies, or documented orientation competencies completed; [...]

Inspectors wroteBased on record review and interview during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure certified nurse aide performance reviews were completed once every 12 months for 2 of 5 certified nurse aides (certified nurse aides #20 and #21) reviewed. Specifically, there was no documented evidence certified nurse aides #20 and #21 who had worked for the facility more than 12 months, had performance reviews completed at least once every 12 months.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #158) reviewed. Specifically, Resident #158 had a diagnosis of dementia and was not provided with preferred person-centered activities.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00330471 and NY00331762) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure the medical provider was promptly notified of radiology results for 1 of 1 resident (Resident #168) reviewed. Specifically, Resident #168 had x-rays ordered by the medical provider, the radiology provider reported the results to the facility, and the results were not relayed to the medical provider timely.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 9/19/22-9/23/22, the facility failed to ensure residents had the right to a dignified existence for 1 of 4 residents (Residents #127) reviewed. Specifically, Resident #127's urinary catheter drainage bag (collects urine) was not covered and was visible in the dining room and from the hallway while the resident was in their room.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 9/19/22-9/23/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 of 12 resident units (Units 5, 7, 9, 11, and 13), for 3 residents (Residents #148, 186, and 416), and for 2 resident rooms (rooms [ROOM NUMBERS]). Specifically, there were multiple unclean, stained, and damaged areas, furniture, and equipment throughout the facility and fruit flies were observed in a dining area. Resident #148 had an unclean wheelchair, linen, furniture, and sticky floors; and Residents #186 and 416 had unclean Broda (positioning) chairs. Additionally, resident rooms [ROOM NUMBERS] had hot water temperatures at the sinks exceeding 120 degrees Fahrenheit (F).

Inspectors wroteBased on record review and interview during the recertification survey conducted 9/19/22-9/23/22, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's nursing needs for 1 of 1 resident (Resident #264) reviewed. Specifically, Resident #264 was care planned to be dependent on 2 with transferring and was transferred by 1.

Inspectors wroteBased on observation, interview and record review during the recertification and abbreviated surveys (NY00299609, NY00300895, NY00293668, and NY00257181) conducted 9/19/22-9/23/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 15 residents (Residents #8, 238, 264, and 386) reviewed. Specifically: - Resident #8 was not assisted with oral care and their toothbrush was observed on their bathroom sink unopened in a plastic wrapper. - Resident #238 was observed in the same clothing for 5 consecutive days. - Resident #264 was not toileted for more than 5 hours and was not supervised at meals as care planned. - Resident #386 was not assisted with meals and was observed eating independently and spilling food.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 9/19/22-9/23/22 the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #171) reviewed. Specifically, Resident #171 was on aspiration (inhaling food into lungs) precautions due to impaired swallowing and was observed consuming their meal in their room unsupervised with the door closed.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00299609) surveys conducted 9/19/22-9/23/22, the facility failed to ensure residents were free of any significant medication errors for 2 of 15 residents (Residents # 33 and#368) reviewed. Specifically, Residents #33 and #368 did not receive blood sugar (blood glucose) monitoring or insulin administration as ordered.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 9/19/22-9/23/22, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal test tray (Resident #355) reviewed. Specifically, Resident #355's replacement meal was not measured for an appropriate and safe internal food temperature range after being reheated and prior to being served to the resident.