That failure was part of an immediate jeopardy violation at Bishop Rehabilitation and Nursing Center, where federal inspectors found the facility systematically ignored mental health recommendations for five residents between January and June 2024. The problems were so severe that inspectors determined residents faced the likelihood of serious injury, serious harm, or death.
The 305-bed facility on James Street failed residents with extensive psychiatric histories including paranoid schizophrenia, traumatic brain injuries, and major depression. Licensed Psychologist #36 made specific recommendations for behavioral approaches and interventions, but administrators never implemented them into residents' care plans.
Resident #41 had perhaps the most alarming pattern. After cutting off a security device and attempting to leave the facility in January, they were hospitalized for psychiatric evaluation. The psychologist documented that the resident "stated they would commit suicide by cop if they were engaged by law enforcement again to be forced to go to the hospital."
The psychologist specifically warned that facility staff should inform law enforcement about "the intention of aggression if confronted by law enforcement." The recommendation never made it to the resident's care plan.
Two weeks later, the resident was "actively threatening to kill themselves" and "threatening to harm other individuals," according to the chief medical officer's notes. The resident was "sitting in their chair physically shaking their hands which appeared to be extremely aggressive movements."
Police were called. The resident was hospitalized again.
Despite multiple psychiatric crises and specific psychologist recommendations about approaching the resident "with empathy and nonthreatening language," the facility's care plan contained only generic interventions like "praise and reinforce appropriate behavior."
Social Worker #37 told inspectors they "were not aware Resident #41 had a history of homicidal and suicidal ideations."
The facility's failures extended beyond documentation. Licensed Practical Nurse #102 had worked at Bishop for only three days when inspectors interviewed them. They completed general orientation on day one, received a brief unit tour on day two, then was assigned to run a medication cart alone on day three.
"On 7/10/2024, they were on a different unit running a medication cart by themselves," inspectors noted.
Multiple nurses told inspectors they had never been observed performing medication administration or wound care, despite facility policies requiring such competency checks. Licensed Practical Nurse #87 said they "wished the facility did more education."
The medication problems were extensive. Licensed Practical Nurse #33 failed two medication observations - first for not cleaning a blood glucose meter, then for having undated water on the medication cart. During remedial training, they scored 100% on a post-test despite marking two answers incorrectly.
The facility's pharmacy consultant never flagged that Resident #147, a diabetic on blood thinners, was consistently refusing both medications. The resident received heparin injections only twice in January and five times from February through May, despite orders for three daily doses.
Laboratory results presented another systemic failure. Resident #529 had abnormal blood work on February 15 showing signs of infection and dehydration - a high white blood cell count of 13.3 and elevated sodium at 149. The results weren't reviewed until February 22, four days after the resident was hospitalized with sepsis and severe pneumonia.
"Earlier intervention could have resulted in a different outcome for the resident," Nurse Practitioner #16 told inspectors.
Resident #153 had a critically low blood sugar of 49 on June 20. The laboratory called the facility the next evening to report the dangerous result. The nurse who took the call said they "should have called a medical provider" but never did. The result wasn't reviewed by medical staff until four days later.
Food service added to residents' problems. During lunch observations, inspectors found corn served at 115 degrees Fahrenheit, yogurt at 62 degrees, and cottage cheese at 67 degrees. Nine residents at a council meeting complained the food wasn't appetizing.
The kitchen's main refrigerator was running at 46-49 degrees Fahrenheit instead of the required temperature below 41 degrees. Staff voluntarily discarded nine crates of milk, multiple cases of juice, cheese, eggs, and other dairy products that had been stored at unsafe temperatures.
Resident #235's case illustrated how multiple system failures converged. The resident had dementia and a history of throwing items from nurses' carts. In February, they "repeatedly threw items from the nursing cart and screamed for the State Police to be called."
Five days later, they "was threatening staff with a pair of scissors and lunged at staff in a threatening manner." When staff tried to retrieve the scissors, "the resident tried to swipe at all staff who attempted." Police were called, and "the resident threw the scissors at the officer."
A psychiatric nurse practitioner recommended decreasing environmental stimuli and implementing specific behavioral interventions. None of those recommendations appeared in the resident's care plan.
Social Worker #92 told inspectors the resident's "history of throwing things off the nurse's medication cart, spitting out their medications, or delusions of believing their medication contained arsenic was not included on the resident's plan of care."
The immediate jeopardy designation was removed July 3 after the facility provided emergency training to social work staff and updated care plans for the five identified residents. But the underlying problems revealed a facility struggling with basic competency requirements across multiple departments.
Assistant Director of Nursing #27, who had been in the role for only six weeks, acknowledged that "employee files needed some improvement and more organization." They told inspectors that "competencies could not be verified if there was no documentation."
The Administrator admitted their training record system was "a work in progress and was not perfect."
For residents like #41, who told the psychologist they felt "angry, defiant, frustrated, and overwhelmed," the facility's systematic failures meant living without the specialized mental health interventions they desperately needed. The psychologist's warnings about suicide and violence went unheeded, leaving both residents and staff at risk.
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
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