Inspection Reports for Bishop Rehabilitation & Nursing Center
918 James St, Syracuse, NY 13203, United States, NY, 13203
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
44.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
778% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
248 residents
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: May 16, 2025
Visit Reason
Complaint Survey with 6 health and 10 life safety code citations, all corrected by June 24, 2025.
Findings
Complaint Survey with 6 health and 10 life safety code citations, all corrected by June 24, 2025.
Deficiencies (16)
ADL care provided for dependent residents
Infection prevention & control
Quality of care
Reasonable accommodations needs/preferences
Residents are free of significant med errors
Safe/clean/comfortable/homelike environment
Building construction type and height
Corridor - doors
Corridor - openings
Elevators
Hazardous areas - enclosure
Illumination of means of egress
Interior wall and ceiling finish
Multiple occupancies - construction type
Sprinkler system - maintenance and testing
Utilities - gas and electric
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: May 16, 2025
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 5/12/2025 to 5/16/2025 to assess compliance with regulatory requirements related to resident care and medication administration.
Findings
The facility failed to ensure that residents unable to perform activities of daily living received necessary care, specifically noting untrimmed and dirty fingernails for Resident #145. Additionally, a significant medication error occurred when Licensed Practical Nurse #4 administered medications intended for Resident #116 to Resident #47, resulting in potential harm but no actual harm.
Deficiencies (2)
Failure to provide adequate care and assistance for activities of daily living, resulting in Resident #145 having long, untrimmed fingernails with brown and black debris underneath.
Failure to ensure residents were free from significant medication errors; Licensed Practical Nurse #4 administered Resident #116's medications to Resident #47, causing asymptomatic hypoglycemia and hypotension.
Report Facts
Residents reviewed: 6
Residents affected: 1
Residents reviewed: 1
Residents affected: 1
Dates of survey: 2025-05-12 to 2025-05-16
Date of medication error: Apr 9, 2025
Glucagon administrations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Administered wrong medications to Resident #47, removed from medication cart responsibilities |
| Certified Nurse Aide #8 | Certified Nurse Aide | Responsible for hygiene care on shower days, did not notice Resident #145's long, dirty nails |
| Certified Nurse Aide #9 | Certified Nurse Aide | Worked overnight shifts, did not clean Resident #145's nails as they did not notice they were dirty |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Stated nail care was important and Resident #145 should have nails clipped and cleaned |
| Assistant Director of Nursing #3 | Assistant Director of Nursing | Oversaw activities of daily living care including nail care, noted brown and black substances under nails as a hygiene issue |
| Nurse Practitioner #5 | Nurse Practitioner | Assessed Resident #47 after medication error, monitored resident and notified Medical Director |
| Registered Nurse Unit Manager #6 | Registered Nurse Unit Manager | Notified of medication error, monitored Resident #47, and coordinated response |
| Licensed Practical Nurse Assistant Unit Manager #7 | Licensed Practical Nurse Assistant Unit Manager | Informed about medication error and took over Licensed Practical Nurse #4's assignment |
| Medical Director | Medical Director | Notified of medication error, confirmed resident stability and no hospitalization required |
| Certified Nurse Aide #28 | Certified Nurse Aide | Reported Resident #47 was non-responsive in the morning and perked up in the afternoon |
| Pharmacist #26 | Pharmacist | Consulted regarding medication error, agreed no additional interventions needed |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 16, 2025
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 5/12/2025 to 5/16/2025 to assess compliance with regulatory requirements for Bishop Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to ensure call bells were within reach for residents, maintaining a safe and clean environment, providing adequate personal care such as nail hygiene, completing wound treatments as ordered, preventing significant medication errors, and implementing an effective infection prevention and control program.
Deficiencies (6)
Failure to ensure call bells were within reach for two residents, posing safety concerns.
Failure to maintain a safe, clean, comfortable, and homelike environment in resident units and pantry area.
Failure to provide adequate personal care, specifically nail care, resulting in long, untrimmed fingernails with debris for one resident.
Failure to complete wound treatments as ordered for two days for one resident.
Significant medication error where one resident was administered medications intended for another resident, including insulin, resulting in past non-compliance with potential for more than minimal harm.
Failure to implement an infection prevention and control program, specifically insulin pens were shared between residents, risking cross contamination.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Dates of survey: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in medication error finding for administering medications intended for another resident. |
| Certified Nurse Aide #11 | Certified Nurse Aide | Observed ignoring call bell on floor for Resident #122. |
| Licensed Practical Nurse #23 | Licensed Practical Nurse | Stated residents should have call bells within reach. |
| Licensed Practical Nurse Unit Manager #12 | Licensed Practical Nurse Unit Manager | Stated call bells should be within reach as resident lifeline. |
| Assistant Director of Nursing #3 | Assistant Director of Nursing | Stated call bells should be within reach to address resident concerns. |
| Certified Nurse Aide #8 | Certified Nurse Aide | Responsible for hygiene care including nail care for Resident #145. |
| Certified Nurse Aide #9 | Certified Nurse Aide | Worked overnight shifts and did not notice dirty nails of Resident #145. |
| Licensed Practical Nurse #16 | Licensed Practical Nurse | Did not complete wound treatments on 5/10/2025 and 5/11/2025 and signed as completed. |
| Registered Nurse Manager #17 | Registered Nurse Manager | Aware of incomplete wound treatments and disciplinary action for Licensed Practical Nurse #16. |
| Licensed Practical Nurse Assistant Unit Manager #7 | Licensed Practical Nurse Assistant Unit Manager | Notified about medication error involving Licensed Practical Nurse #4. |
| Registered Nurse Unit Manager #6 | Registered Nurse Unit Manager | Notified about medication error and monitored Resident #47. |
| Nurse Practitioner #5 | Nurse Practitioner | Assessed Resident #47 after medication error and notified Medical Director. |
| Medical Director | Medical Director | Notified about medication error and provided clinical oversight. |
| Pharmacist #26 | Pharmacist | Consulted regarding medication error. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 19
Date: Dec 20, 2024
Visit Reason
Complaint Survey with 9 health and 11 life safety code citations, all corrected by February 2025.
Findings
Complaint Survey with 9 health and 11 life safety code citations, all corrected by February 2025.
Deficiencies (19)
Dialysis
Food procurement,store/prepare/serve-sanitary
Grievances
License/comply w/ fed/state/locl law/prof std
Personal privacy/confidentiality of records
Posted nurse staffing information
Quality of care
Resident rights/exercise of rights
Safe/clean/comfortable/homelike environment
Building construction type and height
Corridor - doors
Electrical equipment - power cords and extens
Electrical equipment - testing and maintenanc
Fire alarm system - testing and maintenance
Means of egress - general
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Utilities - gas and electric
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 20, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with federal and state regulations for Bishop Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including residents' rights to dignity and privacy, safe and clean environment, grievance resolution timeliness, appropriate treatment and care including dialysis and medication administration, nurse staffing posting, food service standards, and operation of an unapproved dialysis den.
Deficiencies (9)
Resident #110 was not shaved as requested, violating their right to dignity.
Narcotics Logbook containing confidential resident information was left unsecured in a resident's room.
Resident #29's room had black and gray buildup along baseboards indicating inadequate cleaning.
Facility did not ensure prompt resolution of grievances for multiple residents including Resident #127.
Resident #127 did not have Scopolamine patch monitored for placement as ordered, risking increased secretions.
Residents #14 and #29 did not consistently receive dialysis care with proper pre- and post-dialysis assessments and communication.
Facility did not post daily resident census and nurse staffing data in a location readily accessible to residents and visitors.
Two walk-in coolers in the main kitchen were out of service for prolonged periods and working coolers had unclean and uncleanable surfaces.
Facility was operating an unapproved dialysis den not in compliance with federal, state, and local laws and professional standards.
Report Facts
Residents affected: 1
Residents affected: 14
Residents affected: 1
Residents affected: 11
Residents affected: 1
Residents affected: 1
Residents affected: 2
Days staffing not posted accessibly: 5
Walk-in coolers out of service: 2
Dialysis stations: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #15 | Responsible for shaving residents, named in dignity deficiency | |
| Licensed Practical Nurse #16 | Responsible for shaving residents, named in dignity deficiency | |
| Registered Nurse Unit Manager #17 | Registered Nurse Unit Manager | Oversaw shaving duties, named in dignity deficiency and narcotics logbook confidentiality |
| Assistant Director of Nursing #9 | Assistant Director of Nursing | Oversaw shaving duties and narcotics logbook confidentiality |
| Licensed Practical Nurse #18 | Left narcotics logbook unsecured | |
| Light Housekeeper #13 | Responsible for cleaning resident rooms, named in cleanliness deficiency | |
| Director of Social Work | Director of Social Work | Responsible for grievance resolution |
| Licensed Practical Nurse Assistant Unit Manager #22 | Involved in grievance investigations | |
| Social Worker #23 | Handled grievance documentation | |
| Licensed Practical Nurse #31 | Applied Scopolamine patch | |
| Licensed Practical Nurse #33 | Provided suctioning care and monitored Scopolamine patch | |
| Licensed Practical Nurse Assistant Unit Manager #22 | Reported increased coughing and secretions for Resident #127 | |
| Nurse Practitioner #19 | Nurse Practitioner | Provided medical orders and expectations for Scopolamine patch |
| Registered Nurse Unit Manager #27 | Registered Nurse Unit Manager | Oversaw dialysis communication and assessments |
| Licensed Practical Nurse #24 | Documented dialysis assessments | |
| Licensed Practical Nurse #25 | Completed post-dialysis assessments | |
| Licensed Practical Nurse Assistant Unit Manager #26 | Assisted with dialysis assessments | |
| Registered Nurse #29 | Provided in-house dialysis care | |
| Licensed Practical Nurse #28 | Prepared residents for dialysis | |
| Director of Nursing | Director of Nursing | Responsible for dialysis communication and staffing posting |
| Dialysis Administrator #30 | Dialysis Administrator | Managed outside dialysis facility communication |
| Food Service Director | Food Service Director | Oversaw kitchen cleanliness and equipment maintenance |
| Receptionist #2 | Commented on staffing posting location | |
| Staffing Coordinator #1 | Staffing Coordinator | Responsible for posting census and staffing |
| Administrator | Administrator | Informed about unapproved dialysis den construction |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Dec 20, 2024
Visit Reason
The inspection was conducted as part of recertification and abbreviated surveys from 12/16/2024 to 12/20/2024 to assess compliance with regulatory standards related to resident rights, environment, grievance resolution, and treatment and care.
Findings
The facility was found deficient in ensuring residents' rights to dignity and grooming, maintaining a safe and clean environment, timely resolution of grievances, and proper monitoring and administration of treatment orders, specifically the placement of a Scopolamine patch for one resident.
Deficiencies (4)
Resident #110 was unshaven with visible chin and lip hair despite facility policies and care plans supporting grooming according to resident preference.
Resident #29's room had black and gray buildup of dirt and grime along baseboards and walls, indicating inadequate cleaning.
Facility failed to make prompt efforts to resolve grievances for 11 anonymous residents and Resident #127, with delays in notification of grievance resolutions.
Resident #127 did not have their Scopolamine patch monitored for placement as ordered, resulting in periods without the patch and increased secretions.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 11
Residents affected: 1
Grievances filed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #15 | Responsible for shaving residents; stated shaving was not done due to poor lighting | |
| Licensed Practical Nurse #16 | Stated CNAs responsible for shaving and should ask residents if they want to be shaved | |
| Registered Nurse Unit Manager #17 | Stated shaving included in activities of daily living and should be done without residents/family having to ask | |
| Assistant Director of Nursing #9 | Stated CNA responsibility to shave residents and failure to do so was a dignity issue | |
| Light Housekeeper #13 | Responsible for cleaning resident room floors daily including baseboards | |
| Account Manager/Acting Director of Environmental Services | Described housekeeping cleaning policies and acknowledged buildup in Resident #29's room | |
| Director of Social Work | Facility's Grievance Officer responsible for grievance process and timely resolution | |
| Licensed Practical Nurse Assistant Unit Manager #22 | Gathered documents for grievance investigations and provided education to staff | |
| Administrator | Acknowledged delays in grievance response and working to improve timeliness | |
| Social Worker #23 | Handled grievance documents and ensured communication of resolutions | |
| Licensed Practical Nurse #31 | Placed Scopolamine patch behind Resident #127's left ear on 12/14/2024 | |
| Licensed Practical Nurse #33 | Observed Resident #127 without patch, suctioned resident, and placed new patch on 12/17/2024 | |
| Licensed Practical Nurse #32 | Checked placement of Scopolamine patch on 12/14/2024 11:00 PM shift | |
| Licensed Practical Nurse #34 | Checked placement of Scopolamine patch on 12/15/2024 11:00 PM shift and 12/16/2024 11:00 PM shift | |
| Nurse Practitioner #19 | Stated orders must be followed and expected notification if patch was not in place |
Inspection Report
Inspection Report
Census: 248
Deficiencies: 15
Date: Jul 11, 2024
Visit Reason
The extended recertification and abbreviated surveys were conducted to assess compliance with regulatory requirements and investigate complaints related to medication self-administration, pain management, change in condition notifications, pressure ulcer care, mental health services, laboratory result notifications, and staff training.
Findings
The facility failed to ensure safe self-administration of medications, timely pain management, proper notification of significant changes in resident condition, adequate pressure ulcer care, provision of medically related social services, timely review and notification of abnormal lab results, and effective staff training. These failures placed residents at risk for serious harm, resulting in Immediate Jeopardy for resident health and safety.
Deficiencies (15)
Residents #21, #64, #72, #207, and #239 were not assessed for safe self-administration of medications or had physician orders for self-administration. Medications were left unattended or not properly observed.
Resident #37 did not receive Lyrica for 3 days due to medication unavailability and provider was not notified; Resident #147 refused heparin, insulin, and labs for 6 months without provider notification; Resident #153 had critically low blood glucose and provider was not notified timely; Resident #528 had a change in condition without assessment or provider notification, resulting in hospitalization.
Resident #154 did not receive oral hygiene as ordered; Resident #226 did not receive assistance with eating as planned.
Resident #826 had unassessed pressure injuries with no treatments; Resident #271 developed a deep tissue injury after pressure relief orders were not followed; Residents #222 and #265 had pressure ulcer treatments not completed as ordered.
Resident #64 did not have bilateral hand splints applied as ordered and care planned.
Resident #133 had significant weight loss and recommendations for appetite stimulant were not discussed with the medical provider.
Resident #64 did not receive appropriate Bilevel Positive Airway Pressure mask; ports on mask were not plugged affecting treatment efficacy.
Residents #28, #37, and #64 had unresolved pain affecting function and quality of life; pain medications and topical treatments were not administered as ordered.
Residents #41, #126, #153, #235, and #250 with mental health disorders did not receive person-centered mental health interventions or social services follow-up after behaviors or hospitalizations.
Resident #529 had abnormal lab results indicating infection and dehydration not reviewed timely; Resident #153 had critically low blood glucose not promptly addressed; Resident #260 had critical INR not timely notified or assessed.
Medication carts and medication rooms had insulin pens without opened dates or expired, and refrigerators were outside acceptable temperature ranges with mold or ice buildup.
Facility failed to ensure licensed nurses had appropriate competencies and skill sets necessary to provide nursing care and related services, including medication administration and wound care competencies.
Food was not stored at safe temperatures in the main kitchen walk-in coolers; uncleanable surfaces and equipment in disrepair were observed in the kitchen.
Resident #41 exhibited exit seeking behaviors and removed wander alert device; security guard allowed resident to exit facility without proper identification or training; Resident #250 had inconsistent documentation of wander alert device implementation.
Resident #64 did not have bilateral hand splints applied as ordered and care planned, risking worsening contractures.
Report Facts
Residents affected: 248
Medication refusal duration: 6
Weight loss percentage: 11
Weight loss percentage: 8.86
Weight loss percentage: 10.29
Temperature: 62
Temperature: 30
Temperature: 28
Temperature: 46
Temperature: 47
Temperature: 48
Temperature: 49
Temperature: 115
Temperature: 57
Temperature: 62
Temperature: 56
Temperature: 65
Temperature: 67
Temperature: 58
Temperature: 54
Temperature: 67
Temperature: 63
Temperature: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #33 | Licensed Practical Nurse | Documented need for re-education that was completed inaccurately |
| Licensed Practical Nurse #94 | Licensed Practical Nurse | Documented need for re-education that was not completed |
| Registered Nurse #15 | Registered Nurse | Did not have skills competencies and medication administration completed, and did not have annual written competencies completed in a timely manner |
| Registered Nurse #25 | Registered Nurse | Did not have skills competencies and medication administration completed, and did not have annual written competencies completed in a timely manner |
| Licensed Practical Nurse #34 | Licensed Practical Nurse | Did not have skills competencies and medication administration completed, and did not have annual written competencies completed in a timely manner |
| Licensed Practical Nurse #53 | Licensed Practical Nurse | Did not have skills competencies and medication administration completed, and did not have annual written competencies completed in a timely manner |
| Licensed Practical Nurse #88 | Licensed Practical Nurse | Did not have skills competencies and medication administration completed, and did not have annual written competencies completed in a timely manner |
| Registered Nurse #89 | Registered Nurse | Did not have skills competencies and medication administration completed |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Did not have skills competencies and medication administration completed |
| Licensed Practical Nurse #87 | Licensed Practical Nurse | Did not have skills competencies and medication administration completed |
| Licensed Practical Nurse #101 | Licensed Practical Nurse | Did not have skills competencies and medication administration completed |
| Licensed Practical Nurse #28 | Licensed Practical Nurse | Did not have medication administration observations completed |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Jul 11, 2024
Visit Reason
The inspection was conducted as an extended recertification and abbreviated survey to assess compliance with regulatory requirements for Bishop Rehabilitation and Nursing Center.
Findings
The facility failed to ensure physician notification for significant changes in residents' conditions, safe medication administration, appropriate pressure ulcer care, adequate assistance with activities of daily living, proper respiratory care, effective pain management, timely laboratory result notification, and provision of medically related social services. Additionally, the facility did not maintain a safe, clean, and homelike environment and failed to provide palatable and properly tempered food.
Deficiencies (11)
Failure to notify physician and resident representative of significant changes in condition for multiple residents, resulting in harm and immediate jeopardy.
Failure to maintain a safe, clean, comfortable, and homelike environment with multiple environmental issues including damaged furniture, stained ceilings, rodent droppings, and water leaks.
Failure to ensure services met professional standards in medication administration, pressure ulcer care, respiratory care, activities of daily living, pain management, social services, and laboratory testing notifications, resulting in immediate jeopardy and harm.
Failure to provide adequate supervision and assistive devices to prevent accidents, including inadequate management of wander alert devices and elopement risk.
Failure to provide care and assistance with activities of daily living, including oral hygiene and eating assistance.
Failure to provide appropriate pressure ulcer care and prevention, including lack of timely assessment, treatment, and implementation of wound care recommendations.
Failure to provide safe and appropriate respiratory care, including failure to apply and maintain mechanical ventilator mask properly.
Failure to provide safe, appropriate pain management, including failure to administer ordered pain medications and topical treatments, resulting in unresolved pain and diminished quality of life.
Failure to provide medically related social services, including lack of person-centered mental health interventions and follow-up for residents with significant mental health diagnoses and behaviors.
Failure to provide or obtain laboratory tests/services when ordered and promptly notify the ordering practitioner of abnormal or critical results, resulting in delayed interventions and harm.
Failure to ensure food and drink were palatable, flavorful, and served at safe and appetizing temperatures, with multiple resident complaints and observations of improper food temperatures.
Report Facts
Residents affected: 4
Residents affected: 8
Residents affected: 5
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 3
Residents affected: 5
Residents affected: 3
Residents affected: 9
Food temperatures: 115
Food temperatures: 57
Food temperatures: 62
Food temperatures: 56
Food temperatures: 65
Food temperatures: 67
Food temperatures: 58
Food temperatures: 54
Food temperatures: 67
Food temperatures: 63
Food temperatures: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Noted change in Resident #528's condition and notified registered nurse supervisor multiple times |
| Registered Nurse Manager #5 | Registered Nurse Manager | Documented Resident #528's unresponsive status and hospital transfer; interviewed about assessments |
| Director of Nursing | Director of Nursing | Interviewed about change in condition notifications and expectations |
| Certified Nurse Aide #40 | Certified Nurse Aide | Interviewed about Resident #528's condition and care refusals |
| Certified Nurse Aide #91 | Certified Nurse Aide | Interviewed about Resident #528's meal refusals and condition |
| Physician #41 | Physician | Interviewed about Resident #528's condition and notification expectations |
| Registered Nurse Unit Manager #94 | Registered Nurse Unit Manager | Interviewed about medication refusal notification and provider communication |
| Licensed Practical Nurse #49 | Licensed Practical Nurse | Interviewed about medication refusal notification process |
| Physician #10 | Physician | Interviewed about Resident #147's medication refusals and risks |
| Registered Pharmacist #92 | Registered Pharmacist | Interviewed about medication regimen reviews and notification responsibilities |
| Nurse Practitioner #22 | Nurse Practitioner | Interviewed about medication refusal communication and pain management |
| Licensed Practical Nurse #28 | Licensed Practical Nurse | Interviewed about medication availability and notification of Lyrica shortage |
| Registered Nurse #94 | Registered Nurse | Interviewed about medication availability and notification responsibilities |
| Certified Nurse Aide #46 | Certified Nurse Aide | Interviewed about environmental issue reporting |
| Assistant Administrator #48 | Assistant Administrator | Interviewed about clock maintenance and work order training |
| Certified Nurse Aide #47 | Certified Nurse Aide | Interviewed about reporting broken equipment and environmental hazards |
| Assistant Director of Nursing #24 | Assistant Director of Nursing | Interviewed about pressure ulcer prevention and wound care communication |
| Wound Care Registered Nurse #65 | Wound Care Registered Nurse | Interviewed about wound care communication and recommendations |
| Wound Care Physician #3 | Wound Care Physician | Interviewed about wound care referrals and treatment recommendations |
| Certified Nurse Aide #60 | Certified Nurse Aide | Interviewed about resident care instructions and refusal of protective boots |
| Licensed Practical Nurse #62 | Licensed Practical Nurse | Interviewed about reporting skin changes and checking wander alert devices |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed about wheelchair cushion evaluations and communication |
| Nurse Practitioner #16 | Nurse Practitioner | Interviewed about lab result follow-up and pain management |
| Licensed Practical Nurse #34 | Licensed Practical Nurse | Interviewed about medication administration and documentation practices |
| Registered Nurse #89 | Registered Nurse | Interviewed about lab notification and medication administration |
| Licensed Practical Nurse #19 | Licensed Practical Nurse | Interviewed about respiratory care and ventilator mask application |
| Respiratory Therapist #45 | Respiratory Therapist | Interviewed about respiratory care and ventilator mask issues |
| Licensed Practical Nurse Unit Manager #13 | Licensed Practical Nurse Unit Manager | Interviewed about respiratory care and medication administration |
| Registered Nurse Unit Manager #5 | Registered Nurse Unit Manager | Interviewed about weight changes and medication administration |
| Registered Dietitian #43 | Registered Dietitian | Interviewed about nutritional assessments and provider notification |
| Diet Technician #38 | Diet Technician | Interviewed about nutritional assessments and provider notification |
| Resident #37 | Interviewed about pain management and medication availability | |
| Resident #28 | Interviewed about pain management and medication administration | |
| Resident #64 | Interviewed about respiratory care and pain management | |
| Resident #154 | Interviewed about oral care and assistance with activities of daily living | |
| Resident #226 | Interviewed about assistance with eating | |
| Resident #271 | Interviewed about pressure ulcer care and use of protective boots | |
| Resident #529 | Interviewed about laboratory result notification and hospitalization | |
| Resident #153 | Interviewed about laboratory result notification and mental health care | |
| Resident #250 | Interviewed about wander alert device and behavioral symptoms | |
| Security Guard #55 | Security Guard | Interviewed about elopement incident and training |
| Receptionist #56 | Receptionist | Interviewed about elopement incident |
| Nurse Supervisor #23 | Nurse Supervisor | Interviewed about elopement incident and resident supervision |
| Licensed Psychologist #36 | Licensed Psychologist | Interviewed about mental health care and care plan recommendations |
| Psychiatric Mental Health Nurse Practitioner #73 | Psychiatric Mental Health Nurse Practitioner | Interviewed about mental health care and care plan recommendations |
| Social Worker #37 | Social Worker | Interviewed about mental health care and care plan recommendations |
| Director of Social Work | Director of Social Work | Interviewed about mental health care and care plan recommendations |
| Medical Director #11 | Medical Director | Interviewed about laboratory result notification and resident care |
Inspection Report
Covid-19
Capacity: 60
Deficiencies: 1
Date: Jan 19, 2024
Visit Reason
Covid-19 Survey with 1 life safety code citation for sprinkler system out of service, corrected by February 19, 2024.
Findings
Covid-19 Survey with 1 life safety code citation for sprinkler system out of service, corrected by February 19, 2024.
Deficiencies (1)
Sprinkler system - out of service
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 19, 2024
Visit Reason
Complaint Survey with 1 health citation for license compliance, corrected by February 16, 2024.
Findings
Complaint Survey with 1 health citation for license compliance, corrected by February 16, 2024.
Deficiencies (1)
License/comply w/ fed/state/locl law/prof std
Inspection Report
Abbreviated Survey
Census: 26
Deficiencies: 2
Date: Jan 19, 2024
Visit Reason
The abbreviated survey was conducted following a water line break and flooding in the 918 building, which caused evacuation and relocation of 26 residents from 21 rooms. The facility was reviewed for compliance with reporting requirements to the New York State Department of Health and fire safety procedures.
Findings
The facility failed to notify the New York State Department of Health about the evacuation of residents, the water and sprinkler system being taken out of service, and the required fire watch after a broken hot water line caused flooding. Water damage affected multiple resident rooms, and fire department intervention included sprinkler head replacement and fire watch implementation. No residents were harmed and water service was restored the same night.
Deficiencies (2)
Failure to notify the New York State Department of Health about evacuation of residents and loss of water and sprinkler services.
Failure to complete required fire watch as directed by the fire department after sprinkler head replacement.
Report Facts
Residents relocated: 26
Rooms evacuated: 21
Water leak date: Dec 31, 2023
Fire alarm activation time: 2127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Reported details of water pipe break and actions taken to stop leak. | |
| Administrator | Responsible for reporting events; stated event was not reported to NY State Department of Health. | |
| Director of Nursing | Informed about fire watch requirements and responsible for fire watch duties. | |
| Security Guard #11 | Security Guard | Witnessed flooding and called 911; provided details about water and sprinkler events. |
| Deputy Chief #12 | Fire Department Deputy Chief | Described fire department response, sprinkler head replacement, and fire watch requirements. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 5, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 11/27/2023 to 12/5/2023 to assess compliance with federal and state regulations regarding resident care, rights, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, neglect in toileting assistance, failure to provide timely medical follow-up and appointments, improper discharge and transfer procedures, inadequate discharge planning, and failure to provide appropriate treatment and care according to physician orders for several residents. These deficiencies resulted in actual harm or psychosocial harm to residents but did not constitute immediate jeopardy.
Deficiencies (5)
Failure to treat residents with dignity and respect, including inadequate toileting assistance, inappropriate footwear, poor quality linens, and unjustified restrictions on resident passes.
Failure to ensure residents were free from neglect, including failure to assist with toileting and failure to notify medical providers of abnormal blood glucose levels.
Failure to ensure effective transfer or discharge planning, including lack of documentation and communication with receiving facilities, and failure to provide medications timely.
Failure to plan resident discharge to meet goals and needs, including lack of discharge planning and communication with resident expressing intent to discharge.
Failure to provide appropriate treatment and care according to orders, including failure to notify medical providers of abnormal blood glucose, failure to complete neurological checks after falls, failure to schedule and perform diagnostic tests, failure to apply ordered devices such as palm protectors and leg rests, and failure to properly manage wound care including wound vac use.
Report Facts
Blood glucose readings above 300 mg/dL: 7
Wound vac change frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing #3 | Assistant Director of Nursing | Discussed dignity issues related to Resident #109's clothing and shoes, and medication delivery for Resident #265. |
| Licensed Practical Nurse Unit Manager #18 | Licensed Practical Nurse Unit Manager | Acknowledged Resident #109's lack of appropriate clothing and shoes and discussed dignity concerns. |
| Social Worker #25 | Social Worker | Involved in Resident #109's clothing needs and Resident #121's appointment scheduling; discussed discharge planning for Resident #521. |
| Physician #69 | Physician | Responsible for scheduling Resident #121's positron emission tomography scan and discussed importance of follow-up. |
| Registered Nurse Unit Manager #29 | Registered Nurse Unit Manager | Managed visitation and pass restrictions for Resident #522 and discussed communication with resident. |
| Licensed Practical Nurse #13 | Licensed Practical Nurse | Discussed toileting assistance expectations for Resident #31. |
| Licensed Practical Nurse #86 | Licensed Practical Nurse | Discussed blood glucose monitoring and notification procedures for Resident #18. |
| Medical Director | Medical Director | Discussed notification requirements for abnormal blood glucose levels. |
| Nurse Practitioner #21 | Nurse Practitioner | Discussed notification of blood glucose levels and follow-up for Resident #18. |
| Registered Nurse #40 | Registered Nurse | Discussed wound care orders and documentation for Resident #521. |
| Registered Nurse Unit Manager #29 | Registered Nurse Unit Manager | Discussed wound vac discontinuation and documentation for Resident #521. |
| Director of Social Work | Director of Social Work | Discussed discharge planning process and expectations. |
| Social Worker #31 | Social Worker | Discussed discharge planning and resident assessments. |
| Physician #68 | Physician | Discussed importance of palm protectors and leg rests for Resident #55. |
| Certified Nurse Aide #87 | Certified Nurse Aide | Discussed care plan information and use of palm protectors and leg rests for Resident #55. |
| Rehabilitation Director | Rehabilitation Director | Discussed use of palm protectors and leg rests for Resident #55. |
| Certified Nurse Aide #88 | Certified Nurse Aide | Discussed missed application of palm protector and leg rests for Resident #55. |
| Licensed Practical Nurse #55 | Licensed Practical Nurse | Discussed use of palm protectors and leg rests for Resident #55. |
| Registered Nurse Unit Manager #29 | Registered Nurse Unit Manager | Discussed wound vac discontinuation and documentation for Resident #521. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 13, 2023
Visit Reason
Complaint Survey with 1 life safety code citation for evacuation and relocation plan, corrected by November 22, 2023.
Findings
Complaint Survey with 1 life safety code citation for evacuation and relocation plan, corrected by November 22, 2023.
Deficiencies (1)
Evacuation and relocation plan
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Jun 28, 2023
Visit Reason
Complaint Survey with 1 health citation for quality of care, corrected by July 24, 2023, and multiple life safety code citations.
Findings
Complaint Survey with 1 health citation for quality of care, corrected by July 24, 2023, and multiple life safety code citations.
Deficiencies (9)
Quality of care
Corridor - doors
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Hazardous areas - enclosure
Rubbish chutes, incinerators, and laundry chu
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Vertical openings - enclosure
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Jun 28, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards of practice related to medication administration and treatment, specifically regarding the administration of nitroglycerin to Resident #1 who experienced chest pain.
Complaint Details
The visit was complaint-related based on Resident #1's report that LPN #8 administered nitroglycerin too quickly without monitoring blood pressure and failed to document or report the resident's condition. The complaint was substantiated by interviews and record reviews.
Findings
The facility failed to ensure appropriate treatment and care for Resident #1 by administering three doses of nitroglycerin without proper blood pressure monitoring, documentation, or timely communication between staff. The resident's blood pressure dropped significantly, and they were transferred to the hospital. The nursing staff and management did not follow protocols or clarify orders adequately.
Deficiencies (3)
Failure to monitor blood pressure before and after administering nitroglycerin and failure to document medication administration and vital signs.
Failure of LPN Manager to follow up with staff, monitor the resident, notify supervisors, and communicate with the oncoming shift.
Nitroglycerin order lacked specific blood pressure parameters and was not clarified with a medical provider prior to implementation.
Report Facts
Nitroglycerin doses administered: 3
Blood pressure readings: 85
Blood pressure readings: 121
Blood pressure readings: 131
Medication dose: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #8 | Licensed Practical Nurse | Administered three doses of nitroglycerin without proper blood pressure monitoring or documentation. |
| LPN Manager #9 | Licensed Practical Nurse Manager | Failed to follow up with staff, monitor the resident, notify supervisors, and clarify nitroglycerin order parameters. |
| LPN #7 | Licensed Practical Nurse | Oncoming nurse who was not informed about the resident's condition or nitroglycerin administration. |
| RNS #6 | Registered Nurse Supervisor | Assessed resident after nitroglycerin administration and transferred resident to hospital. |
| NP #16 | Nurse Practitioner | Provided expert opinion on proper nitroglycerin administration protocol. |
| DON | Director of Nursing | Provided statements on expected nursing protocols and order clarifications. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 25
Date: May 24, 2023
Visit Reason
Complaint Survey with 20 health and 9 life safety code citations, all corrected by July 19, 2023.
Findings
Complaint Survey with 20 health and 9 life safety code citations, all corrected by July 19, 2023.
Deficiencies (25)
Activities meet interest/needs each resident
ADL care provided for dependent residents
Competent nursing staff
Develop/implement comprehensive care plan
Discharge planning process
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Investigate/prevent/correct alleged violation
Label/store drugs and biologicals
Maintains effective pest control program
Medicaid/medicare coverage/liability notice
Nutritive value/appear, palatable/prefer temp
Resident call system
Resident rights/exercise of rights
Resident self-admin meds-clinically approp
Residents are free of significant med errors
Respiratory/tracheostomy care and suctioning
Safe/clean/comfortable/homelike environment
Treatment/svcs to prevent/heal pressure ulcer
Tube feeding mgmt/restore eating skills
Corridor - doors
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Hazardous areas - enclosure
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 11
Date: May 24, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 5/15/23 to 5/24/23 to assess compliance with regulatory requirements for Bishop Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, safe and homelike environment, comprehensive person-centered care planning, discharge planning, assistance with activities of daily living, feeding tube administration, respiratory care, medication administration, infection prevention and control, pest control, and provision of meaningful activities.
Deficiencies (11)
Resident #39 was not assisted with accessing a telephone and was unable to communicate with persons outside the facility, violating resident rights to communication and dignity.
Facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment with multiple unclean or damaged floors, walls, ceilings, and maintenance issues in resident rooms and common areas.
The facility did not ensure implementation of comprehensive person-centered care plans for Residents #9 and #193, including failure to provide assistance as planned for activities of daily living and toileting.
The facility did not ensure discharge needs were identified and discharge plans developed for Residents #11 and #182, resulting in lack of appropriate referrals and assistance for discharge to community or assisted living.
Residents who were unable to carry out activities of daily living did not receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, including poor oral hygiene and untrimmed fingernails, lack of assistance with eating, and failure to provide showers as planned.
Resident #235's tube feeding was not administered as ordered, with missing documentation and failure to provide prescribed nutritional support.
Resident #302 received BiPAP therapy without a physician order for administration or resident specific settings, risking improper respiratory care.
Licensed practical nurse (LPN) #2 administered the incorrect insulin to Resident #303 resulting in a significant medication error requiring emergency intervention.
Food and drink were not served at palatable and appetizing temperatures for meals observed on 5/16/23 and 5/17/23.
During wound care for Resident #235, licensed practical nurse (LPN) #64 and registered nurse (RN) #3 failed to perform hand hygiene appropriately and used the same washcloth to cleanse soiled and clean areas, risking infection.
The facility did not maintain an effective pest control program, with multiple house flies observed in resident rooms on D unit and the third floor.
Report Facts
Tube feeding volume: 240
Insulin units administered: 70
Temperature: 48
Temperature: 57
Temperature: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Administered incorrect insulin to Resident #303 resulting in medication error |
| RN #3 | Registered Nurse | Supervised LPN #2 and responded to medication error incident |
| LPN #64 | Licensed Practical Nurse | Failed to perform hand hygiene during wound care for Resident #235 |
| RN #1 | Registered Nurse Unit Manager | Assessed Resident #303 after medication error and coordinated emergency response |
| RN #43 | Registered Nurse | Reported awareness of house flies in resident rooms and pest control procedures |
| LPN #42 | Licensed Practical Nurse | Responsible for pest management log and reported lack of awareness of flies in some rooms |
| LPN #14 | Licensed Practical Nurse | Conducted resident room rounds and reported no awareness of house flies in some rooms |
| CNA #66 | Certified Nurse Aide | Observed providing care not consistent with care plan for Residents #9 and #193 |
| CNA #20 | Certified Nurse Aide | Observed providing oral and nail care to Resident #235 |
| CNA #18 | Certified Nurse Aide | Observed providing meal assistance to Resident #108 |
| LPN #65 | Licensed Practical Nurse | Documented tube feeding administration and provided statements regarding nutrition care |
| RD #22 | Registered Dietitian | Provided nutrition assessments and recommendations for Resident #235 |
| RT #78 | Respiratory Therapist | Provided BiPAP therapy and education for Resident #302 |
| RN Infection Preventionist #4 | Registered Nurse Infection Preventionist | Provided infection control guidance and observations |
| Recreation Aide #74 | Recreation Aide | Provided activity services and observations for Resident #103 and #235 |
| Director of Nursing | Director of Nursing | Oversaw medication error investigation and staff orientation processes |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided statements on care plan adherence and infection control |
| Physician #79 | Physician | Provided medical orders and statements regarding BiPAP and nutrition |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Mar 5, 2023
Visit Reason
Complaint Survey with 3 health citations including a Level 3 severity for treatment/services to prevent/heal pressure ulcers, all corrected by March 31, 2023.
Findings
Complaint Survey with 3 health citations including a Level 3 severity for treatment/services to prevent/heal pressure ulcers, all corrected by March 31, 2023.
Deficiencies (3)
Investigate/prevent/correct alleged violation
Pain management
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Mar 5, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate allegations of abuse and to assess compliance with care standards related to abuse prevention, pressure ulcer care, and pain management.
Complaint Details
The visit was complaint-related, triggered by allegations of abuse involving a certified nurse aide (CNA) being rough with Resident #12. The complaint was substantiated with findings of delayed investigation and failure to remove the accused CNA from resident care during the investigation.
Findings
The facility failed to prevent further potential abuse by not promptly investigating allegations or removing the accused staff from resident care. Additionally, the facility did not provide appropriate pressure ulcer care for a resident, resulting in progression to a Stage 4 ulcer, and failed to provide timely and adequate pain management for a resident after a fall.
Deficiencies (3)
Failed to prevent potential abuse, delayed investigation for 3 days, and failed to remove accused CNA from resident care pending investigation.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in a Stage 4 pressure ulcer with actual harm.
Failed to provide safe and appropriate pain management for a resident who required such services, including failure to communicate severe pain to medical staff and delayed hospital transfer.
Report Facts
Days delayed in abuse investigation: 3
Protein supplement order delay: 14
Wound size: 9
Wound size: 7
Wound size: 0.1
Pain level: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Unit Manager #12 | Licensed Practical Nurse Unit Manager | Named in pain management deficiency and abuse investigation findings |
| LPN #23 | Wound Nurse | Named in wound care deficiency and interview regarding wound treatment delays |
| Wound Physician #22 | Wound Care Physician | Named in wound care deficiency and treatment recommendations |
| Wound Physician #31 | Wound Care Physician | Named in wound care deficiency and treatment evaluations |
| NP #9 | Nurse Practitioner | Named in pain management deficiency and interview regarding pain assessment and treatment |
| LPN #18 | Licensed Practical Nurse | Named in pain management deficiency and interview regarding pain medication administration |
| LPN #26 | Former Wound Nurse | Named in wound care deficiency and interview regarding therapy evaluation and wound treatment |
| RD #24 | Registered Dietitian | Named in wound care deficiency and interview regarding nutritional assessment and supplement delays |
| RNS #24 | Registered Nurse Supervisor | Named in wound care deficiency and abuse investigation |
| LPN #17 | Licensed Practical Nurse | Named in pain management deficiency and medication administration |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Jan 19, 2023
Visit Reason
Complaint Survey with 6 health citations including a Level 4 severity for free of accident hazards/supervision/devices indicating immediate jeopardy, all corrected by February 7, 2023.
Findings
Complaint Survey with 6 health citations including a Level 4 severity for free of accident hazards/supervision/devices indicating immediate jeopardy, all corrected by February 7, 2023.
Deficiencies (6)
Administration
Develop/implement comprehensive care plan
Free of accident hazards/supervision/devices
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Safe/clean/comfortable/homelike environment
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 21
Date: Nov 2, 2022
Visit Reason
Complaint Survey with 22 health and 16 life safety code citations, all corrected by December 17, 2022.
Findings
Complaint Survey with 22 health and 16 life safety code citations, all corrected by December 17, 2022.
Deficiencies (21)
ADL care provided for dependent residents
Administration
Criminal history record check process
Dialysis
Essential equipment, safe operating condition
Facility assessment
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Frequency of meals/snacks at bedtime
Infection prevention & control
Label/store drugs and biologicals
Other laws, codes, rules and regulations.
Provided diet meets needs of each resident
Quality of care
Resident call system
Resident rights/exercise of rights
Respiratory/tracheostomy care and suctioning
Responsibilities of providers; required notif
Safe/clean/comfortable/homelike environment
Sufficient dietary support personnel
Tube feeding mgmt/restore eating skills
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Sep 7, 2022
Visit Reason
Complaint Survey with 6 health citations, all corrected by October 10, 2022.
Findings
Complaint Survey with 6 health citations, all corrected by October 10, 2022.
Deficiencies (6)
Investigate/prevent/correct alleged violation
Menus meet resident nds/prep in adv/followed
Nutritive value/appear, palatable/prefer temp
Quality of care
Resident rights/exercise of rights
Residents are free of significant med errors
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