Loretto Health And Rehabilitation Center
Inspection Findings
F-Tag F0584
F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
schedule and the certified nurse aides would put the chairs in the hall on the night shift. 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 floorDuring 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)
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If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loretto Health and Rehabilitation Center
700 East Brighton Avenue Syracuse, NY 13205
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0610
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.
F-Tag F0676
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.
F-Tag F0679
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.
F-Tag F0689
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.
F-Tag F0695
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.
F-Tag F0697
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.
F-Tag F0698
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.
F-Tag F0761
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.
F-Tag F0804
F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
plated the food. If the food did not look the way it should, kitchen staff should make the Director of the Commissary aware. They stated the acquired test tray temperatures were out of range. Soups were made
on the units and that may be why they tasted bland. 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)
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If continuation sheet
F-Tag F0812
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.
F-Tag F0880
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.
F-Tag F0925
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.
LORETTO HEALTH AND REHABILITATION CENTER in SYRACUSE, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SYRACUSE, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LORETTO HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.