Bishop Rehab: Critical Lab Results Delayed - NY
The delays created immediate jeopardy to resident health and safety, with the likelihood of serious injury, serious harm, or death, federal inspectors found during a July survey.
The facility's Medical Director described a corporate system that had systematically excluded physicians from decision-making. During a telephone interview on July 10, the Medical Director said they previously had input into admissions and resident services, participated in daily operations, and worked as an integral part of resident care.
"They used to have to sign off on the policies and procedures and was advised of and made aware of policy and procedure changes," the inspection report states. The Medical Director said they thought the facility was pulling most policies from the corporate level.
When they raised concerns about policies and procedures to the Director of Nursing, "they felt they were not being heard."
The Medical Director said they were unsure who to speak to beyond the Director of Nursing. "The facility corporation was a complex system and ran things in layers and was filtered down to the facility. There were many people involved in who the facility would admit and how facility staff provided care to the residents."
Nurse Practitioner #22, who worked with the Medical Director for multiple years, told inspectors during a July 9 interview that corporate administration did not include providers in administrative discussions. The corporate takeover had changed everything.
"Prior to the corporate takeover of the facility the provider had some input into the admission and services for incoming residents, the day to day operations of the facility, and the needs of the residents," the practitioner said. "The providers used to be an integral part of the residents care and now they were not as involved."
The facility's Administrator, interviewed July 11, claimed the Medical Director participated in quality assurance meetings, plan of correction work, and rehospitalization meetings. The Administrator said policies come from the corporate team and the Medical Director should be aware of all policies.
But the Medical Director painted a different picture. They said they currently had no input regarding facility policies and had never heard about the facility assessment document. "In the past they would review residents and decide if the facility was able to accommodate and appropriately care for the new resident."
Now, corporate policies were "corporate driven" and while physicians provided insight as requested, "the corporation had their own way of doing things."
The critical lab results violation was part of a broader pattern of training failures that affected 33 of 36 staff files reviewed by inspectors. The facility failed to ensure staff received mandatory training in communication, resident rights, abuse prevention, quality assurance, infection control, compliance and ethics, and mental health care.
Staff interviews revealed widespread gaps in basic training. Certified Nurse Aide #90 attended approximately four hours of general orientation but could not remember specific job training. They had no memory of receiving education on communicating with English-as-a-second-language residents or non-verbal residents.
"They were not sure if they had received mental/behavior health care training, they recalled watching something on a screen and signing for it," inspectors noted.
Licensed Practical Nurse #28 told inspectors they did not receive weekly education or training. They had no education on English as a second language at the facility and were unaware of quality assurance or performance improvement goals.
"They had never seen anyone come onto the unit to watch hand hygiene. They did not receive education or training for mental and behavioral health needs," the report states.
Patient Service Liaison #108 attended an eight-hour general orientation but received no job-specific training. They had no education on communicating with English-as-a-second-language residents or non-verbal residents, could not recall any quality improvement topics, and did not know how to bring concerns to the quality committee.
Business Office Manager #121, hired in May 2019, received two days of general orientation but no ongoing training or competencies except at corporate level for new programs. They never received training for mental and behavioral health care needs or dementia care.
Licensed Practical Nurse #53, hired in January 2023, said people should be on orientation longer. They only received training weekly "if someone did something wrong and there was re-education."
They received no formal communication training. "Some residents had the translator information in their room but there was no formal education," they told inspectors.
Central Service Assistant #124, who also worked overtime hours as a certified nurse aide, received no education for non-verbal or English-as-a-second-language residents. They had suggested that type of education to the previous educator, recognizing it was important to communicate with all residents.
Licensed Practical Nurse #98 had one day of specific orientation and no ongoing training or competencies. "They received no other training other than State concerns," inspectors found. They did not know current quality improvement goals or how to bring concerns to the committee.
Certified Nurse Aide #128 was not sure if they received specific job orientation. They had no ongoing training, no education on communicating with non-verbal or English-as-a-second-language residents, and were unaware of what quality improvement was.
Maintenance Technician #21 was taught during orientation to find a nurse if someone did not know who they were or why they were there when communicating with residents who were non-verbal or spoke English as a second language. They did not know what quality improvement was and received no training on quality goals.
The facility's training requirements, documented in its May 2024 Facility Assessment Portfolio, called for comprehensive annual mandatory education including abuse reporting, fire safety, resident rights, infection control, communication with diverse populations, and mental health care.
But staff consistently reported missing these basic trainings. Security Guard #111 attended general orientation but had no specific job training and no ongoing education. Patient Service Liaison #109 started work on a Monday, attended general orientation on Thursday, then received no ongoing training on communication, quality assurance, or mental health needs.
Assistant Director of Nursing/Nurse Educator #27, responsible for all staff education, told inspectors on July 10 they were unable to give a definitive answer about how education was tracked.
The Administrator and Director of Nursing said during a July 11 interview that education focused on the plan of correction rather than comprehensive staff development. They held townhall meetings once or twice monthly to discuss the plan of correction and how to avoid repeated deficiencies.
The Director of Nursing said the education program was "geared more towards the regulatory results" rather than matching resident needs identified in the facility assessment.
Multiple staff members could not locate personnel files for four employees, including Patient Service Liaison #108, Dietary Staff #112, Certified Occupational Therapy Assistant #116, and Authorization Specialist #121.
The training failures occurred against the backdrop of a facility where medical leadership felt systematically excluded from care decisions. The Medical Director's description of corporate layers filtering down policies, combined with widespread staff training gaps, created conditions where critical lab results could go unnoticed.
Three residents paid the price when their abnormal lab values fell through the cracks of a system where physicians had been pushed to the margins and staff lacked basic training to recognize when immediate medical attention was required.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bishop Rehabilitation and Nursing Center from 2024-07-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
BISHOP REHABILITATION AND NURSING CENTER in SYRACUSE, NY was cited for violations during a health inspection on July 11, 2024.
The facility's Medical Director described a corporate system that had systematically excluded physicians from decision-making.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.