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Deficiency Records for Loretto Health and Rehabilitation Center
A list of the most recent deficiencies for Loretto Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Loretto Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-04-23 | 2024-06-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-04-23 | 2024-06-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-23 | 2024-06-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-23 | 2024-06-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-04-23 | 2024-06-21 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-04-23 | 2024-06-21 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2024-04-23 | 2024-06-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-04-23 | 2024-06-21 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-04-23 | 2024-06-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-04-23 | 2024-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-23 | 2024-06-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-23 | 2024-06-21 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-04-23 | 2024-06-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-23 | 2024-06-21 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-04-23 | 2024-06-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-23 | 2024-06-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-23 | 2024-06-21 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-04-23 | 2024-06-21 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-04-23 | 2024-06-21 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-04-23 | 2024-06-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-04-23 | 2024-06-21 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-04-23 | 2024-06-21 | N |
| Use approved construction type or materials. | Fire Safety | 2024-04-23 | 2024-06-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-04-23 | 2024-06-21 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-04-23 | 2024-06-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-23 | 2024-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-23 | 2024-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-23 | 2024-06-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-23 | 2024-06-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-04-23 | 2024-06-21 | N |
| Respond appropriately to all alleged violations. | Health | 2023-06-22 | 2023-08-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-22 | 2023-08-21 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-23 | 2022-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-23 | 2022-11-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-23 | 2022-11-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-23 | 2022-11-18 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-23 | 2022-11-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-23 | 2022-11-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-23 | 2022-11-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-23 | 2022-11-18 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-23 | 2022-11-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-23 | 2022-11-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-23 | 2022-11-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-23 | 2022-11-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-08 | 2020-03-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-01-08 | 2020-03-06 | N |
| Respond appropriately to all alleged violations. | Health | 2020-01-08 | 2020-03-06 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-08 | 2020-03-06 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2020-01-08 | 2020-03-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-08 | 2020-03-06 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-01-08 | 2020-03-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-08 | 2020-03-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-08 | 2020-03-06 | N |
| Ensure gas and vacuum piping is labeled. | Fire Safety | 2020-01-07 | 2020-03-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-07 | 2020-03-06 | N |
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