Inspection Summary

Apr 2022 – Mar 2026
73%
of inspections passed with no issues found
16 of 22 inspections · Apr 2022 – Mar 2026
Inspections with issues
6 of 22 inspections
Total violations cited
17 violations total
What the violations were about
Environmental standards 7Resident services 6Admission & retention standards 1Personnel 1Pre-submission requirements 1Records & reports 1
In plain language
  • The most recent inspection was on March 10, 2026 (relicensure, follow-up survey) and found no violations.
  • Across 22 inspections in the current reporting window, 16 found no violations at all; inspectors cited 17 violations in total.
  • Of the 22 visits in this window, 18 were prompted by complaints and 4 were routine or other surveys.
  • The state has 1 formal enforcement action on record for this facility.

A violation is a rule breach noted by a state inspector. Most are administrative and get corrected through an approved plan of correction; the sections below show exactly what was cited and the status of each correction plan.

Provider Information

Type
Enriched Housing Program
Operating Certificate
520-S-054
County
Onondaga
Phone
(315) 469-7786
Operated By
Loretto Adult Community, Inc.
DOH Regional Office
Central New York Regional Office

Inspection Details

Apr 2022 – Mar 2026
ℹ Violations under dispute through the Inspection Review Process (IRP) are not displayed.
March 10, 2026 Relicensure, Follow-up Survey 0 Violations

✓ No violations found

January 12, 2026 Complaint Survey 0 Violations

✓ No violations found

September 3, 2025 Relicensure Survey 2 Violations
Resident services
Regulation cited: CFR 488.7 (d) (3)
Plan/Notice of Correction Approved
Environmental standards
Regulation cited: CFR 488.11 (e) (3)
Plan/Notice of Correction Approved
August 19, 2025 Complaint Survey 0 Violations

✓ No violations found

June 26, 2025 Complaint Survey 0 Violations

✓ No violations found

March 25, 2025 Complaint Survey 0 Violations

✓ No violations found

February 4, 2025 Complaint Survey 0 Violations

✓ No violations found

January 29, 2025 Complaint Survey 2 Violations
Admission and retention standards
Regulation cited: CFR 488.4 (c) (5)
Plan/Notice of Correction Approved
Resident services
Regulation cited: CFR 488.7 (e) (2)
Plan/Notice of Correction Approved
September 26, 2024 Relicensure, Follow-up Survey 0 Violations

✓ No violations found

July 31, 2024 Complaint Survey 0 Violations

✓ No violations found

April 5, 2024 Relicensure Survey 7 Violations
Requirements before submitting a request for
Regulation cited: CFR 402.5(c)
Plan/Notice of Correction Approved
Resident services
Regulation cited: CFR 488.7 (d) (3)
Plan/Notice of Correction Approved
Environmental standards
Regulation cited: CFR 488.11 (d) (1)
Plan/Notice of Correction Approved
Environmental standards
Regulation cited: CFR 488.11 (e) (6)
Plan/Notice of Correction Approved
Environmental standards
Regulation cited: CFR 488.11 (e) (13)
Plan/Notice of Correction Approved
Environmental standards
Regulation cited: CFR 488.11 (g) (3)
Plan/Notice of Correction Approved
Environmental standards
Regulation cited: CFR 488.11 (g) (6)
Plan/Notice of Correction Approved
January 17, 2024 Complaint Survey 0 Violations

✓ No violations found

November 28, 2023 Complaint Survey 2 Violations
Resident services
Regulation cited: CFR 488.7 (e) (2)
Plan/Notice of Correction Approved
Records and reports
Regulation cited: CFR 488.10 (c) (1)
Plan/Notice of Correction Approved
October 25, 2023 Complaint Survey 0 Violations

✓ No violations found

July 17, 2023 Complaint Survey 0 Violations

✓ No violations found

April 28, 2023 Complaint Survey 1 Violation
Resident services
Regulation cited: CFR 488.7 (d) (3)
Plan/Notice of Correction Approved
April 7, 2023 Relicensure, Complaint, Follow-up Survey 0 Violations

✓ No violations found

March 16, 2023 Complaint Survey 0 Violations

✓ No violations found

March 1, 2023 Complaint Survey 0 Violations

✓ No violations found

February 28, 2023 Complaint Survey 0 Violations

✓ No violations found

January 12, 2023 Relicensure, Complaint Survey 3 Violations
Resident services
Regulation cited: CFR 488.7 (d) (3)
Plan/Notice of Correction Approved
Personnel
Regulation cited: CFR 488.9 (a) (2) (v)
Plan/Notice of Correction Approved
Environmental standards
Regulation cited: CFR 488.11 (e) (13)
Plan/Notice of Correction Approved
July 21, 2022 Complaint Survey 0 Violations

✓ No violations found

Enforcement & Orders

Apr 2022 – Mar 2026
1 enforcement action — Stipulation & Order agreement signed with the NY Department of Health.
August 8, 2024
Stipulation & Order
#ACF-24-025