Loretto Health and Rehabilitation: Maintenance Failures - NY
The Director of Maintenance told the inspector that staff first flagged the damaged ceiling tile about three weeks before the inspection, on a Friday. They replaced it. By Monday, it needed to come down again. The problem was a leaking heating and cooling pipe, and fixing it properly would require shutting down the entire floor's climate system for at least three hours. The vendor hadn't come back yet. The repair was waiting for a stretch of mild weather, when temperatures outside wouldn't put residents at risk during the shutdown.
That explanation put the facility in an uncomfortable position: acknowledging a known infrastructure problem, a tile replaced twice, a vendor called, a repair deferred, while residents on that floor lived underneath it.
The ceiling wasn't the only thing inspectors noticed.
Window shades on the thirteenth floor were dirty. The Director of Housekeeping told the inspector that cleaning window shades was part of the deep-clean checklist that staff were supposed to work through daily. If a housekeeper couldn't get a shade clean with standard supplies, the process called for reporting it to a crew leader, trying a different cleaning method, and ultimately contacting maintenance to order a replacement. If housekeeping couldn't clean it, maintenance would install a new one when it arrived.
None of that happened on the thirteenth floor. The Director of Housekeeping said no one had reported any shades needing extra attention or replacement up there. The Director of Maintenance said the same thing: no notification had come in for the thirteenth floor at all.
So the shades sat dirty. Not because the system didn't have a process. Because nobody in the chain had passed the information along.
Wheelchairs presented a similar pattern. The Director of Housekeeping described a cleaning schedule built around the overnight shift, with a staff member working four days a week assigned specifically to chairs. Rooms that received a deep clean were supposed to get wheelchair cleaning as part of it. Beyond that, any staff member who spotted a dirty chair was expected to clean it on the spot.
The inspection was rated as causing minimal harm or potential for actual harm, and the deficiency affected some residents. The citation was not at the level of immediate jeopardy. But the picture it drew wasn't of a single oversight. It was of a building where the same corrective tile went back up twice without the root cause being addressed, where a floor's worth of window shades went unreported through a process that existed specifically to catch that problem, and where the gap between what the checklist required and what staff actually communicated had become routine enough that two department directors, independently, said they simply hadn't heard anything was wrong.
The maintenance director's answer about the pipe repair, that the vendor needed to wait for cooler weather, was reasonable on its face. Shutting down a floor's heating and cooling in the middle of summer to fix a pipe is a genuine logistical problem. But the tile had come down twice. Residents on that floor had been living under a ceiling that kept failing, with the permanent fix still somewhere in the future.
The inspection was completed August 29, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Loretto Health and Rehabilitation Center from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 19, 2026 · Our methodology
LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY was cited for violations during a health inspection on August 29, 2025.
The Director of Maintenance told the inspector that staff first flagged the damaged ceiling tile about three weeks before the inspection, on a Friday.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.