Loretto Health And Rehabilitation Center
LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY — inspection on August 29, 2025.
Found 13 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 8/29/2025 at 12:02 PM, the Director of Maintenance stated they were made aware of the resident room ceiling tile on the 5th floor on a Friday about three weeks ago.
They replaced it and by Monday the tile needed to be replaced again.
They called the vendor for the leak and changed the tile again.
There was a repair done, but it was a heating and cooling pipe, so the repair would require the system on that floor to be unable to heat or cool for approximately three hours at the minimum.
The vendor had to come when the temperature was not going to be too hot outside. If housekeeping was unable to clean a window shade, they should order a new one.
Once the new item came in, they notified maintenance to install the shade.
They were not notified to install any window shades on the thirteenth floor
During an interview on 8/29/2025 at 12:16 PM, the Director of Housekeeping stated staff had checklists to be completed daily for their room cleaning.
Window shades were part of the deep clean, and they should be cleaned if dirty as part of the room cleaning. If the housekeeper was unable to get them clean, they should report it to the crew leader or them and they would attempt to clean it with something different. If they still were not clean, they would contact maintenance to have them replaced.
They stated they were not notified of any additional cleaning needed or replacements for the thirteenth floor.
The process for cleaning wheelchairs was on the 3rd shift schedule.
They had a staff member that worked 4 days a week to clean chairs.
Rooms assigned a deep clean got wheelchair cleaning also. If staff saw a dirty chair, they were expected to clean it when they saw it. 10 NYCRR 415.29(j)(1)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Loretto Health and Rehabilitation Center
700 East Brighton Avenue Syracuse, NY 13205
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0610 during a standard health inspection conducted on 2025-08-29.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Respond appropriately to all alleged violations.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0676 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0679 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide activities to meet all resident's needs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0697 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0698 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-29.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: 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.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.
During an interview on 8/29/2025 at 1:09 PM, Commissary Director #14 stated they made the food, including the entrees, starches, eggs, and cereal.
They also prepared the different consistencies.
The food was cooked in the commissary, and the cooks should taste the food.
Each meal was cooked 5 days in advance.
The pot roast should have some liquid in the pan to keep it moist.
The roast was precooked from a vendor and only sliced by the facility.
Once the food was sent to the tray line and plated, the trays were placed on a cart, the cart was sent to the assigned unit, and the carts were placed in a machine to warm/heat the food.
Each cart was placed in a machine, and the warming timer was set by dietary staff.
The temperature differences may have been due to the food positioning on the plate. 10NYCRR 415.14(d)(1)(2)
Facility ID:
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-29.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-29.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.
Federal health inspectors cited LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY for a deficiency under regulatory tag F-F0925 during a standard health inspection conducted on 2025-08-29.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 13 deficiencies cited during this inspection of LORETTO HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-28.