Bishop Rehab: Untreated Pressure Injuries - NY
The resident was hospitalized two more times. Each time they returned with the same pressure injuries. Each time, staff failed to get them assessed by a qualified professional or start treatments.
Another resident had doctor's orders for pressure relief boots to prevent injury while in bed. Staff never put the boots on. The resident developed a deep tissue injury on their right heel — a localized area of purple and maroon discolored skin caused by damage to underlying tissue.
Federal inspectors found that wound care recommendations for this resident were ignored. The person needed a wheelchair cushion evaluation and orders to leave their brief open to air. Neither happened.
Two other residents had documented pressure ulcers with orders for daily dressing changes. The dressings weren't changed as ordered.
The pattern extended beyond individual cases. Inspectors determined that many residents were affected by the facility's failures in pressure injury prevention and treatment.
Resident 826's case illustrated the human cost of inadequate care. After being readmitted from the hospital with existing pressure injuries, the wounds went without professional assessment. No treatments were provided for the sacrum and heel injuries despite the resident's vulnerable condition following hospitalization.
The cycle repeated. Hospital discharge, readmission to the nursing home, no wound assessment, no treatment plan. Then another hospitalization. The same sequence played out again with the same result — pressure injuries left untreated upon the resident's return.
For Resident 271, the failure was more specific but equally harmful. Medical orders clearly stated that pressure relief boots should be worn while in bed. The boots sat unused while the resident's heel sustained damage that could have been prevented.
Deep tissue injuries represent serious medical conditions. The purple and maroon discoloration indicates damage has already occurred to tissue beneath the skin's surface. Without proper intervention, these injuries can worsen rapidly.
The facility also ignored specific wound care recommendations that could have prevented further deterioration. A wheelchair cushion evaluation would have addressed pressure points during the resident's time out of bed. Leaving the brief open to air would have reduced moisture and friction that contribute to skin breakdown.
Residents 222 and 265 faced different but related problems. Both had existing pressure ulcers that required daily dressing changes according to their care plans. The routine maintenance of these wounds was not completed as medical orders specified.
Daily dressing changes serve multiple purposes for pressure ulcer care. They allow staff to monitor healing progress, prevent infection, and maintain the wound environment necessary for tissue repair. When these changes don't happen as ordered, wounds can deteriorate or fail to heal.
Federal inspectors classified the violations as causing actual harm to residents, though not rising to the level of immediate jeopardy. The determination reflected the serious nature of pressure injury complications and the facility's systematic failures in wound care.
The inspection found that the problems affected many residents beyond those specifically cited in the report. This suggests widespread deficiencies in the facility's approach to pressure injury prevention and treatment rather than isolated incidents.
Pressure injuries represent one of the most preventable complications in nursing home care. Proper positioning, regular turning, appropriate support surfaces, and timely treatment of early-stage injuries can prevent the serious wounds that developed at Bishop Rehabilitation and Nursing Center.
The consequences for residents extended beyond physical harm. Multiple hospitalizations disrupt care continuity and can be traumatic for elderly residents. For Resident 826, the repeated cycle of hospital discharge and readmission without proper wound care created an ongoing medical crisis that proper nursing home protocols could have prevented.
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 resident was hospitalized two more times.
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.