Inspection Reports for
Loretto Health and Rehabilitation Center
700 E Brighton Ave, Syracuse, NY 13205, United States, NY, 13205
Back to Facility Profile5 Reports
Inspection Report — Mar 10, 2026
Complaint Investigation State
Date: Mar 10, 2026
Visit Reason
State-compiled facility profile showing 8 inspections from June 2022 to May 2026 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 430 complaints about this facility with 43 on-site inspections conducted. Complaint-related citations numbered 23 during the reporting period.
Findings
Across 8 inspections, 5 resulted in citations totaling 99 deficiencies primarily related to standard health and life safety code issues, mostly Level 2 minor potential harm. The facility had 430 complaints with 43 on-site inspections and 3 enforcement actions totaling $31,000 in fines.
Citations (42)
Standard Health Citation — quality of care: Treatment/services to prevent or heal pressure ulcers were deficient.
Standard Health Citation — quality of care: Activities of daily living maintenance abilities were deficient.
Standard Health Citation — quality of care: Activities met interest/needs of each resident were deficient.
Standard Health Citation — quality of care: Dialysis care was deficient.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving sanitary practices were deficient.
Standard Health Citation — quality of care: Facility was not free of accident hazards or lacked supervision/devices.
Standard Health Citation — quality of care: Infection prevention and control was deficient.
Standard Health Citation — quality of care: Investigation, prevention, and correction of alleged violations were deficient.
Standard Health Citation — quality of care: Labeling and storage of drugs and biologicals were deficient.
Standard Health Citation — quality of care: Effective pest control program was not maintained.
Standard Health Citation — quality of care: Nutritive value, appearance, palatability, and preferred temperature of food were deficient.
Standard Health Citation — quality of care: Pain management was deficient.
Standard Health Citation — quality of care: Respiratory/tracheostomy care and suctioning were deficient.
Standard Health Citation — quality of care: Safe, clean, comfortable, homelike environment was deficient.
Standard Health Citation — quality of care: ADL care provided for dependent residents was deficient.
Standard Health Citation — quality of care: Competent nursing staff was deficient.
Standard Health Citation — quality of care: Development and implementation of comprehensive care plan was deficient.
Standard Health Citation — quality of care: Discharge planning process was deficient.
Standard Health Citation — quality of care: Free from involuntary seclusion was deficient.
Standard Health Citation — quality of care: Grievances were not properly handled.
Standard Health Citation — quality of care: Nurse aide performance review and in-service training were deficient.
Standard Health Citation — quality of care: Personal privacy and confidentiality of records were deficient.
Standard Health Citation — quality of care: Radiology/diagnostic services ordered and notification of results were deficient.
Standard Health Citation — quality of care: Reasonable accommodations for needs and preferences were deficient.
Standard Health Citation — quality of care: Resident rights and exercise of rights were deficient.
Standard Health Citation — quality of care: Treatment/service for dementia was deficient.
Standard Health Citation — quality of care: Residents were not free of significant medication errors.
Life Safety Code Citation — NFPA requirements: Electrical equipment power cords and extensions were deficient.
Life Safety Code Citation — NFPA requirements: Gas and vacuum piped systems information and maintenance were deficient.
Life Safety Code Citation — NFPA requirements: Hazardous areas enclosure was deficient.
Life Safety Code Citation — NFPA requirements: Means of egress general conditions were deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing were deficient.
Life Safety Code Citation — NFPA requirements: Utilities gas and electric systems were deficient.
Life Safety Code Citation — NFPA requirements: Building construction type and height were deficient.
Life Safety Code Citation — NFPA requirements: Doors with self-closing devices were deficient.
Life Safety Code Citation — NFPA requirements: Egress doors were deficient.
Life Safety Code Citation — NFPA requirements: Electrical equipment testing and maintenance were deficient.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system were deficient.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance were deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation was deficient.
Life Safety Code Citation — NFPA requirements: Subdivision of building spaces smoke barriers were deficient.
Life Safety Code Citation — NFPA requirements: Subsistence needs for staff and patients were deficient.
Report Facts
Inspections on page: 8
Total violations/deficiencies cited: 99
Inspections with violations: 5
Inspections without violations: 3
Total complaints: 430
On-site inspections from complaints: 43
Total enforcement actions: 3
Total fines: 31000
Citations from complaints: 23
Inspection Report — Aug 29, 2025
Annual Inspection CMS
Date: Aug 29, 2025
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 8/25/2025 to 8/29/2025 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, and homelike environment; inadequate investigation and reporting of injuries of unknown origin; lack of appropriate translation services; insufficient activity programming; unsafe mechanical lift transfers; improper respiratory care; inadequate pain management; incomplete dialysis assessments; improper medication storage and labeling; food served at inappropriate temperatures; unsanitary kitchen conditions; failure to implement infection control precautions; and ineffective pest control program.
Citations (13)
F 0584: The facility failed to ensure a safe, clean, and homelike environment for four of fourteen resident units, including soiled linens on floors, stained ceiling tiles, unclean privacy curtains, and dirty wheelchairs.
F 0610: The facility did not thoroughly investigate and report injuries of unknown origin for one resident, failing to notify the state within 24 hours as required.
F 0676: The facility did not provide appropriate treatment and services to maintain or improve activities of daily living, including failure to provide translation services for a resident with limited English proficiency.
F 0679: The facility did not provide meaningful activities consistent with resident interests and preferences for one resident, including failure to offer activities during staff absence.
F 0689: The facility failed to ensure adequate supervision and safe use of mechanical lifts, transferring residents requiring two-person assistance with only one staff member.
F 0695: The facility did not provide safe and appropriate respiratory care for one resident, including failure to clean bilevel positive airway pressure mask as ordered, resulting in brown debris in the mask.
F 0697: The facility failed to provide safe, appropriate pain management for one resident, including failure to apply prescribed pain patch as ordered and lack of documentation of pain treatment effectiveness.
F 0698: The facility did not provide safe, appropriate dialysis care for two residents, including failure to complete pre- and post-dialysis assessments as ordered and incomplete documentation.
F 0761: The facility failed to ensure drugs and biologicals were stored and labeled according to professional standards, including unlocked medication and treatment carts, expired and undated medications, and unlocked medication cart screens.
F 0804: The facility did not ensure food was served at palatable and appetizing temperatures, with test trays showing bland taste and improper temperatures, and residents reporting cold and overcooked food.
F 0812: The facility failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including expired foods, out-of-range refrigerator temperatures, and unclean kitchen areas with standing water and food debris.
F 0880: The facility failed to implement an effective infection prevention and control program, including staff not wearing required gowns and gloves during enhanced barrier precautions for one resident.
F 0925: The facility did not maintain an effective pest control program, with persistent fruit flies observed in multiple kitchens and resident areas despite vendor treatments.
Report Facts
Resident units reviewed: 14
Residents reviewed: 8
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 3
Residents reviewed: 3
Medication carts reviewed: 13
Treatment carts reviewed: 14
Medication storage rooms reviewed: 7
Kitchen and kitchenettes reviewed: 18
Days with out-of-range refrigerator temperatures: 23
Fruit fly sightings: 15
Inspection Report — Apr 23, 2024
Annual Inspection CMS
Date: Apr 23, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 4/15/2024 to 4/23/2024 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, accommodation of resident needs, privacy violations, environmental cleanliness, grievance process, involuntary seclusion, care planning, activities of daily living assistance, supervision, pain management, medication labeling and storage, food safety, staff competencies, and dementia care.
Citations (16)
F 0550: The facility failed to ensure residents were treated with dignity and respect, as evidenced by residents sitting in soiled bedding and unkempt personal hygiene.
F 0558: The facility did not reasonably accommodate resident needs and preferences, such as providing accessible bathroom sinks for residents with hemiplegia.
F 0583: The facility failed to protect residents' personal and medical records privacy, posting identifiable information in public areas visible to others.
F 0584: The facility did not ensure a safe, clean, comfortable, and homelike environment, with issues including dirty rooms, sticky floors, pest infestations, and unclean resident-use equipment.
F 0585: The facility did not provide adequate information or access to file anonymous grievances, as residents were unaware of grievance procedures and officers.
F 0603: The facility failed to prevent involuntary seclusion by restricting a resident's movement due to unfilled portable oxygen tanks, limiting their participation in activities and socialization.
F 0656: The facility did not develop and implement comprehensive person-centered care plans for residents, including failure to address smoking privileges, pressure injury prevention devices, and discharge planning.
F 0677: The facility failed to provide necessary assistance for activities of daily living, resulting in poor nutrition, grooming, hygiene, and positioning for multiple residents.
F 0689: The facility did not ensure adequate supervision and accident hazard prevention for residents at risk of falls or with behavioral issues, including failure to lock bed brakes and monitor wandering residents.
F 0697: The facility failed to provide adequate pain management for a resident following a fall with a hip fracture, including failure to evaluate pain and obtain pain medication orders.
F 0726: The facility did not ensure licensed nurses completed required annual competencies and orientation documentation timely.
F 0730: The facility did not complete annual performance reviews for certified nurse aides as required.
F 0744: The facility failed to provide appropriate treatment and services to a resident with dementia, including failure to provide preferred person-centered activities and adequate socialization.
F 0761: The facility did not ensure drugs and biologicals were labeled and stored according to professional standards, including unlabeled nicotine patches, expired medications, unlabeled insulin and inhalers, and unclean medication refrigerators.
F 0777: The facility did not promptly notify the medical provider of radiology results for a resident with a hip fracture, delaying appropriate pain management and treatment.
F 0804: The facility did not ensure food and drink were palatable, flavorful, and served at safe and appetizing temperatures, with cold foods served above safe temperature limits.
Report Facts
Deficiencies cited: 16
Fall Risk Evaluation score: 24
Food temperature: 65
Food temperature: 59
Food temperature: 54
Food temperature: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #43 | Named in dignity and respect deficiency related to Resident #384 not being cleaned timely after vomiting | |
| Certified Nurse Aide #44 | Named in dignity and respect deficiency related to Resident #384 care | |
| Registered Nurse Unit Manager #14 | Named in dignity and respect deficiency and shower care refusals | |
| Director of Nursing | Named in multiple interviews regarding dignity, laundry, grievance process, oxygen tank issues, and fall prevention | |
| Certified Nurse Aide #8 | Named in dignity and respect deficiency and shower care refusals | |
| Licensed Practical Nurse Unit Manager #4 | Named in oxygen tank deficiency and shower care refusals | |
| Certified Nurse Aide #77 | Named in smoking and care plan deficiency for Resident #201 | |
| Registered Nurse Unit Manager #27 | Named in privacy violation and behavioral supervision deficiencies | |
| Social Worker #29 | Named in discharge planning and behavioral supervision deficiencies | |
| Licensed Practical Nurse #46 | Named in pain management and medication labeling deficiencies | |
| Licensed Practical Nurse #48 | Named in pain management and medication labeling deficiencies | |
| Licensed Practical Nurse Unit Manager #40 | Named in fall prevention deficiency | |
| Certified Nurse Aide #38 | Named in fall prevention deficiency related to bed brakes not locked | |
| Licensed Practical Nurse Unit Manager #33 | Named in staff competency deficiency | |
| Licensed Practical Nurse #24 | Named in staff competency deficiency | |
| Certified Nurse Aide #63 | Named in activities of daily living deficiency | |
| Licensed Practical Nurse #67 | Named in activities of daily living deficiency | |
| Registered Nurse Unit Manager #66 | Named in activities of daily living deficiency | |
| Licensed Practical Nurse #6 | Named in medication labeling deficiency | |
| Registered Nurse Unit Manager #27 | Named in medication cart and food storage deficiencies | |
| Licensed Practical Nurse #73 | Named in medication labeling deficiency | |
| Licensed Practical Nurse #74 | Named in medication labeling deficiency | |
| Licensed Practical Nurse #13 | Named in medication refrigerator deficiency | |
| Assistant Director of Nursing #23 | Named in medication labeling deficiency | |
| Licensed Practical Nurse #45 | Named in pain management deficiency | |
| Licensed Practical Nurse #52 | Named in pain management deficiency | |
| Physician #53 | Named in pain management deficiency | |
| Licensed Practical Nurse #20 | Named in certified nurse aide performance review deficiency | |
| Registered Nurse Unit Manager #28 | Named in certified nurse aide performance review deficiency | |
| Certified Nurse Aide #70 | Named in dementia care deficiency | |
| Licensed Practical Nurse #46 | Named in dementia care deficiency | |
| Licensed Practical Nurse Unit Manager #52 | Named in pain management and dementia care deficiency | |
| Certified Nurse Aide #30 | Named in behavioral supervision deficiency | |
| Licensed Practical Nurse #31 | Named in behavioral supervision deficiency | |
| Registered Nurse Unit Manager #40 | Named in fall prevention deficiency | |
| Certified Nurse Aide #38 | Named in fall prevention deficiency | |
| Licensed Practical Nurse #39 | Named in fall prevention deficiency | |
| Director of Staff Education and Development | Named in staff competency deficiency | |
| Licensed Practical Nurse Assistant Unit Manager #33 | Named in fall prevention and staff competency deficiency | |
| Certified Nurse Aide #21 | Named in certified nurse aide performance review deficiency | |
| Director of Human Resources | Chief People Officer | Named in certified nurse aide performance review deficiency |
| Director of Food Services #57 | Named in food temperature deficiency | |
| Diet Technician #58 | Named in food temperature deficiency | |
| Food Service Supervisor | Named in food temperature deficiency |
Inspection Report — Jun 22, 2023
Abbreviated Survey CMS
Date: Jun 22, 2023
Visit Reason
The abbreviated survey was conducted to investigate alleged violations related to Resident #2 sustaining skin tears of unknown origin and to assess compliance with supervision and investigation policies.
Findings
The facility failed to thoroughly investigate alleged violations for Resident #2 who sustained multiple skin tears of unknown origin. The resident was placed on one-to-one supervision but was not provided direct supervision as ordered, resulting in a skin tear. The investigation did not address whether supervision was provided as ordered and did not rule out abuse or neglect.
Citations (2)
F 0610: The facility did not ensure all alleged violations were thoroughly investigated for Resident #2 who sustained skin tears of unknown origin. The investigation did not address the resident's order for one-to-one supervision or whether it was provided as ordered.
F 0689: The facility did not ensure adequate supervision to prevent accidents for Resident #2 placed on one-to-one direct supervision. The resident was not provided direct supervision and sustained a skin tear of unknown origin.
Report Facts
Falls: 12
Skin tears: 2
ISM shifts signed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Assigned to provide one-to-one supervision (ISM) for Resident #2 on 10/23/2022; stated they did not provide care due to staffing issues and could not recall providing ISM at the time of the skin tear. |
| RN Manager #8 | Registered Nurse Manager | Completed the Incident Accident Investigation on 10/28/2022 and conducted interviews related to Resident #2's skin tear and supervision. |
| RNS #5 | Registered Nurse Supervisor | Notified the on-call provider of Resident #2's skin tear on 9/6/2022 and was responsible for initiating investigation. |
| RNS #6 | Registered Nurse Supervisor | Responded to the skin tear incident on 10/23/2022 and documented no reasonable cause to suspect abuse or neglect. |
| Administrator | Administrator | Interviewed on 6/22/2023 regarding ISM policy and supervision of Resident #2. |
| Director of Nursing | Director of Nursing (DON) | Interviewed on 6/22/2023 regarding ISM policy and supervision of Resident #2. |
Inspection Report — Sep 23, 2022
Annual Inspection CMS
Date: Sep 23, 2022
Visit Reason
The survey was a recertification survey conducted from 9/19/22 to 9/23/22 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including residents' dignity and privacy, environmental cleanliness and maintenance, care planning and implementation, assistance with activities of daily living, supervision to prevent accidents, medication administration errors, and food safety and palatability.
Citations (7)
F 0550: The facility failed to ensure residents' right to a dignified existence for 1 of 4 residents reviewed; Resident #127's urinary catheter drainage bag was uncovered and visible in multiple locations.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment for 3 residents and multiple units due to unclean furniture, damaged walls, stained ceilings, loose windowsills, and presence of fruit flies.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #264, who was care planned for total dependence on 2 staff for transfers but was transferred by 1.
F 0677: The facility failed to ensure residents unable to perform activities of daily living received necessary assistance; Residents #8, 238, 264, and 386 had deficiencies in oral care, clothing changes, toileting, meal assistance, and hygiene.
F 0689: The facility failed to provide adequate supervision to prevent accidents for Resident #171, who was on aspiration precautions but was observed eating unsupervised in their room with the door closed.
F 0760: The facility failed to ensure residents were free from significant medication errors; Residents #33 and #368 did not receive blood glucose monitoring or insulin administration as ordered due to missed diabetic tab documentation and lack of staff training.
F 0804: The facility failed to ensure food was palatable, attractive, and at a safe temperature; Resident #355's replacement meal was reheated without measuring internal temperature to confirm safety.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #40 | Certified Nursing Assistant | Named in oral care deficiency for Resident #8 |
| RN Unit Manager #9 | Registered Nurse Unit Manager | Named in care plan and medication administration deficiencies |
| LPN #41 | Licensed Practical Nurse | Named in care plan and supervision deficiencies |
| CNA #45 | Certified Nursing Assistant | Named in supervision and toileting deficiencies for Resident #264 |
| NP #22 | Nurse Practitioner | Named in medication error follow-up |
| SLP #47 | Speech Language Pathologist | Named in aspiration precautions deficiency for Resident #171 |
| Food Service Director | Named in food temperature deficiency | |
| Administrator | Named in food temperature deficiency |
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