SYRACUSE, NY - Federal inspectors identified multiple immediate jeopardy violations at Bishop Rehabilitation and Nursing Center during a July 2024 investigation, finding serious failures in medical monitoring, pain management, and mental health services that put residents at risk of serious harm or death.
Laboratory Monitoring Failures Lead to Emergency Hospitalizations
The most serious violation involved the facility's failure to promptly review and respond to abnormal laboratory results. Three residents experienced potentially life-threatening situations when critical blood work was not properly monitored by nursing staff or communicated to physicians in a timely manner.
Resident #529 faced the most severe consequences from these monitoring failures. Laboratory tests conducted on February 15, 2024, revealed multiple abnormal values indicating possible infection and dehydration, including a dangerously high white blood cell count of 13.3 units per microliter (normal range: 4.1-11.0) and elevated sodium levels of 149 millimoles per liter (normal range: 136-145). The laboratory flagged these results as abnormal on February 16, but facility staff did not review them until February 22 - four days after the resident was hospitalized.
The resident was transferred to the hospital on February 18 with sepsis, acute respiratory failure, and severe dehydration. Hospital records showed the resident's white blood cell count had increased to 19 units per microliter and sodium levels reached 161 millimoles per liter, requiring intensive care treatment with antibiotics, intravenous fluids, and steroids for severe pneumonia.
Resident #153 experienced a critically low blood glucose reading of 49 milligrams/deciliter (normal range: 70-99) on June 20, 2024. The laboratory called this critical result to the facility on June 21 at 5:46 PM, but no medical provider was notified and the resident was not assessed for signs of potentially dangerous hypoglycemia. Low blood glucose can cause confusion, seizures, coma, or death if not promptly treated.
Resident #260, who had an artificial heart valve requiring careful blood-thinning medication monitoring, had dangerously high International Normalized Ratio (INR) readings of 5.77 and 5.05 on consecutive days in June 2024. These levels, far above the therapeutic range of 2.5-3.5, significantly increased bleeding risk. While the facility eventually held the resident's blood thinner medication, there was no documentation that physicians were promptly notified of these critical values.
The laboratory monitoring failures represent a breakdown in a fundamental safety process. Abnormal laboratory values serve as early warning signals that allow medical providers to intervene before conditions become life-threatening. When these results are not reviewed or communicated promptly, residents face increased risks of complications, emergency hospitalizations, and potentially preventable medical crises.
Pain Management Deficiencies Compromise Quality of Life
Federal inspectors found that three residents did not receive ordered pain medications as prescribed, creating immediate jeopardy conditions throughout the facility for all residents receiving pain management.
Resident #28 was prescribed diclofenac gel four times daily for knee and shoulder pain but repeatedly told inspectors they were not receiving the medication. During interviews, the resident reported pain levels of 8-9 on a 10-point scale when getting up or transferring, stating "I can't get up in the morning because of the pain" and that the gel significantly improved their mobility when administered.
Nursing records showed the medication was documented as given even when it was not administered. One nurse admitted to signing for medications before actually providing them, explaining they would "come back later" to apply topical treatments but sometimes forgot or ran out of time. This practice of pre-signing medication records creates false documentation and prevents accurate tracking of what residents actually receive.
Resident #37 experienced a three-day period without receiving Lyrica, a critical nerve pain medication for diabetic neuropathy. The resident's pain levels were documented as 7-8 during this period, and they reported the pain was so severe it affected their breathing, ultimately requiring hospitalization on June 24. The medication was available in the facility's emergency dispensing system, but staff failed to access it despite the resident's significant pain complaints.
Resident #64 was unaware they had orders for as-needed pain medications and topical pain cream, despite reporting pain levels of 6-10. The resident had multiple orders for acetaminophen and diclofenac gel but never received either medication during the month of June 2024, according to medication records.
Effective pain management is essential for residents' quality of life, functional abilities, and overall well-being. Untreated pain can lead to decreased mobility, depression, social isolation, and reduced participation in rehabilitation activities. The facility's failures in pain management created a pattern of documented harm affecting residents' daily functioning and psychological well-being.
Mental Health Services Inadequately Address Behavioral Needs
Inspectors identified significant deficiencies in mental health services for five residents with serious psychiatric conditions, finding that licensed psychologist recommendations were not incorporated into care plans and behavioral interventions were not person-centered.
Resident #41, who had schizoaffective disorder with a history of suicidal and homicidal ideations, did not receive appropriate behavioral interventions despite multiple incidents requiring police intervention and psychiatric hospitalizations. A licensed psychologist provided specific recommendations for approaching the resident with "empathy and non-threatening language" and warned that the resident had threatened to "commit suicide by cop" if confronted by law enforcement. These critical safety recommendations were not included in the resident's care plan.
The resident had multiple behavioral episodes documented between January and March 2024, including threatening staff, removing security devices, and making statements about harming themselves and others. Despite these serious incidents and detailed recommendations from mental health professionals, the facility's care plan contained only generic interventions without person-specific approaches.
Resident #153 was recommended for a traumatic brain injury program by a licensed psychologist who noted the resident would benefit from "more activity and behavioral support" and "possible community-based integration." This recommendation was never investigated or implemented, despite the resident's ongoing aggressive behaviors and medication refusals.
Resident #235 had escalating behavioral incidents culminating in threatening staff with scissors, requiring police intervention and psychiatric hospitalization. Despite recommendations from a psychiatric nurse practitioner to "decrease environmental stimuli" and "implement behavior interventions such as distraction measures," no specific person-centered interventions were developed or documented in the care plan.
The lack of appropriate mental health interventions creates risks not only for the affected residents but also for other residents and staff. Without proper behavioral support and person-centered approaches, residents with mental health conditions may experience worsening symptoms, increased medication needs, and preventable psychiatric emergencies.
Additional Issues Identified
Inspectors documented several other concerning patterns affecting resident care and safety. Multiple residents did not receive proper assistance with daily activities as ordered, including oral hygiene for a resident with swallowing difficulties and meal assistance for a resident with dementia and significant weight loss.
The facility also failed to provide appropriate pressure ulcer prevention and treatment for several residents, with some developing new injuries due to inadequate use of protective equipment and positioning devices. Food service issues were identified, with meals not meeting temperature requirements and multiple residents reporting poor food quality.
Respiratory care deficiencies were found when a resident requiring specialized breathing equipment did not receive proper mask application, and safety supervision was inadequate for residents at risk of wandering or elopement.
The inspection revealed systemic issues in multiple areas of care that collectively created an environment where residents faced increased risks of preventable complications and substandard quality of life. These findings demonstrate the need for comprehensive improvements in staff training, care plan development, and quality monitoring systems to ensure resident safety and well-being.
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.
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