Bishop Rehabilitation And Nursing Center

F-F554.

Residents #21, #64, #72, #207, and #239 were not assessed to determine their ability to safely self-administer medications or had physician orders for self-administration of medication. The facility's failure to ensure residents' medications were safely administered placed all 248 residents at risk for serious harm or serious adverse outcomes. This resulted in Immediate Jeopardy to resident health and safety.

Pain Management Refer to the citation text under

F-F580):

- Resident #37 did not receive their Lyrica from the day shift (7:00 AM-3:00 PM) of 6/22/2024 until day shift of 6/24/2024 due to the facility not having the resident's ordered medication and the provider was not notified.

This resulted in putting residents who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care.

- Resident #147 refused heparin, insulin, and labs as ordered for a period of 6 months, the medical provider was not notified and there was not an assessment by the provider.

- Resident #153 had a low blood glucose level that was reported to the facility by the lab on 6/22/2024 and

the provider was not notified. This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety.

- Resident #528 had a change in condition and was not assessed by a qualified professional when the change was noted, the medical provider was not notified, and the resident's representative was not notified. Subsequently, the resident was hospitalized with severe dehydration. This resulted in harm to Residents #528 and #37 that was not immediate jeopardy.

Activities of Daily Living (

F-F677):

- Resident #154 did not receive oral hygiene as ordered.

- Resident #226 did not receive assistance with eating as care planned.

Pressure Ulcer Services (

F-F686):

- Resident #826 was readmitted from the hospital with pressure injuries of the sacrum and heel, the areas were not assessed by a qualified professional, and there were no treatments provided for the areas. The resident was re-hospitalized on two subsequent occasions, had pressure injuries of the sacrum and heels,

the areas were not assessed timely by a qualified professional or provided with treatments following readmission.

- Resident # 271 had orders for pressure relief boots to be worn while in bed and the boots were not applied. Subsequently, the resident developed a deep tissue injury (localized area of purple/maroon discolored intact skin due to damage of underlying tissue) area to their right heel. Additionally, there were wound care recommendations for a wheelchair cushion evaluation and for the resident's brief to be left open to air that were not implemented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 - Resident #222 and #265 both had documented pressure ulcers with orders for daily dressing changes that were not completed as ordered. Level of Harm - Actual harm

This resulted in harm and Substandard Quality of Care to Residents #271 and #826 that was not immediate Residents Affected - Many jeopardy.

Limited Range of Motion (

F-F688):

- Resident #64 did not have bilateral hand splints in place as ordered and care planned.

Maintaining Acceptable Parameters of Nutritional Status (

F-F692):

- Resident #133 had a significant weight loss and recommendations for an appetite stimulant were not discussed with the medical provider.

Respiratory Care (

F-F695), Pain Management (F 697), and Medication Storage and Labeling (F 761).

Findings included:

The undated facility job description for the Facility Educator documented the Educator was responsible for planning, organizing, developing, implementing, facilitating, and evaluating all employee's education programs throughout the facility, in accordance with the Company's policies and procedures and current applicable Federal, State, Local standards, guidelines and regulations to assure the highest degree of quality resident care can be maintained at all times. The essential functions of the role included working in collaboration with all facility department directors in the orientation and education of staff to ensure mandatory and regulatory education requirements were met within the facility; conducting competencies in areas of nursing practice with attention to management of the medically complex patient; regularly conduct education needs assessment for the facility to assist in identifying areas for improvement; assume the authority, responsibility, and accountability of directing the in-service educational programs as required or directed for compliance with Federal, State, and corporate policy. They were to maintain attendance and documentation of in-services in accordance with regulatory guidelines and corporate policies.

The facility policy, Medication Administration, revised 1/2021, documented new personnel authorized to administer medications would not be permitted to prepare or administer medications until they had been oriented to the medication administration system used by the facility. Newly licensed nurses would receive oversight on medication administration from current licensed nurses who would establish competency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 The Facility Assessment Portfolio, revised 5/3/2024, documented specific care or practices included assessment of pain, pharmacologic and nonpharmacological pain management, pressure injury prevention Level of Harm - Minimal harm or and care, skin care, wound care, contracture prevention/care, and early identification of potential for actual harm problems/deterioration. Upon hiring all facility personnel participated in general orientation and job specific orientation to provide the employees with an in-depth review of policies, procedures, and evidence-based Residents Affected - Many practices that would assist in providing high quality care. Registered Nurses and Licensed Practical Nurses received one day of general orientation, and 2 days of classroom, preceptorship, and further training as determined by nursing leadership. The required competencies included, person-centered care, behavior management, medication administration, treatment competency, and pain management.

The facility document Licensed Nurse Skills Competency revised 5/13/2020, documented the following skills:

- verbalized the understanding of recognizing and reporting change of condition and demonstrated documentation required.

- verbalized the understanding and demonstrated proper documentation guidelines and protocols.

- verbalized the understanding/demonstrated completion requirements for assessments/evaluations.

- verbalized the understanding for pressure ulcer prevention practice guideline - wound protocols, wound documentation, and measurement.

- verbalized the understanding of pain management practice guideline.

- verbalized the understanding of hydration management guideline.

- verbalized the understanding of weight management policy.

- demonstrated proficiency in changing dressings for wounds per policy.

- demonstrated proper hand washing.

- proficiently completed medication administration pass.

- successfully completed medication delivery system for receiving and transcribing orders correctly.

- proficiently completed [electronic medical record] assessment.

- proficiently completed progress note.

Nursing Personnel Records documented the most current annual competencies as follows:

Licensed Practical Nurse #33 had:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 - Medication Administration Observation completed on 2/14/2024 by Licensed Practical Nurse #49, with no concerns. Level of Harm - Minimal harm or potential for actual harm - Licensed Nurse Skills completed on 2/14/2024 by Licensed Practical Nurse #49, the checklist documented

the need for training on suctioning; integumentary (skin) assessment skill, accessing policy and procedure Residents Affected - Many guidelines on the intranet, proper insertion nasogastric tube skills, trach care skills, exposure control plan understanding, and receiving and transcribing orders were not completed. There was no documented evidence that additional training/education was provided.

- Medication administration observation completed on 6/4/2024 by Assistant Director of Nursing/Nurse Educator #27 documented the water on the medication cart was not dated, and the glucometer was not cleaned after each patient use. The comment section documented the need for re-orientation on medication administration in the facility.

- Medication Administration Lesson Plan completed with Assistant Director of Nursing/Nurse Educator #27

on 6/5/2024 with a pre and post-test. The pre-test documented 86% correct, and the post-test documented 100% correct. Upon review of the post-test, there were 2 questions that were marked correct, inaccurately.

- Medication Administration Observation completed on 6/5/2024 by Assistant Director of Nursing/Nurse Educator #27 documented the cleaning of the glucometer after use was not observed. The comment section documented the medication pass competency was achieved.

Registered Nurse #94 completed medication administration observation on 2/14/2024 with Licensed Practical Nurse #64. Licensed Practical Nurse #64 documented, No, for there were no [over the counter] medications on top of the [medication] cart. The form documented that any area with no indicated the need for a comment. No comments were documented on the form. There was no evidence provided for re-education regarding the documentation of over-the-counter medications on top of the medication cart.

Assistant Director of Nursing, Registered Nurse #25 did not have documented evidence of licensed nurse skills competency, to include wound care, or medication administration observation competency. The Yearly Written Competency 2023 was completed 2/20/2023.

Registered Nurse #15 did not have documented licensed nurse skills competencies, including wound care, or medication administration observation competency. The Yearly Written Competency 2023 did not have a date of completion.

Licensed Practical Nurse #88 did not have documented evidence of licensed nurse skills competency, to include wound care, or medication administration observation competency. The Yearly Written Competency 2023 was completed 2/20/2023.

Licensed Practical Nurse #53 did not have documented evidence of licensed nurse skills competency, to include wound care, or medication administration observation competency. The Yearly Written Competency 2023 was completed 2/23/2023.

Licensed Practical Nurse #34 did not have documented evidence of licensed nurse skills competency, to include wound care, or medication administration observation competency. The Yearly Written Competency 2023 was completed 2/20/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Licensed Practical Nurse #101 did not have documented evidence of licensed nurse skills competency, to include wound care, or medication administration observation competency. Level of Harm - Minimal harm or potential for actual harm Registered Nurse #89 did not have documented evidence of licensed nurse skills competency, to include wound care, or medication administration observation competency. Residents Affected - Many Licensed Practical Nurse #2 did not have documented evidence of licensed nurse skills competency, to include wound care, or medication administration observation competency.

Licensed Practical Nurse #87 did not have documented evidence of licensed nurse skills competency, to include wound care, or medication administration observation competency, based on record review of the hardcopy personnel record on 6/27/2024 at 11:53 AM, secure file transfer requests were not received by the facility.

Licensed Practical Nurse #28 did not have documented evidence of medication administration observation.

During an interview on 6/6/2024 at 12:48 PM, Licensed Practical Nurse #33 stated they received re-education on 6/5/2024 by Assistant Director of Nursing/Nurse Educator #27 regarding not leaving medications at the bedside.

During an interview on 6/12/2024 at 12:29 PM, Assistant Director of Nursing/Nurse Educator #27 stated they were responsible for staff education, and other than orientation they did not remember providing education to anyone. If a staff member needed education, they would be asked at morning report or they would get a call from the Director of Nursing, Administrator, or the Unit Manager. Medication administration was completed

during orientation. The Respiratory Therapy department completed education for respiratory equipment.

They did not know if Licensed Practical Nurse #33 was provided education on suctioning, if it was not completed, it should have been. They did provide additional training for Licensed Practical Nurse #33, as the Unit Manager was concerned about medication left at the bedside.

During an interview on 7/1/2024 at 2:16 PM, Assistant Director of Nursing/Nurse Educator #27 stated they were the Nurse Educator for the last month and a half. The employee files needed some improvement and more organization. The Registered Nurses and Licensed Practical Nurses should have a checklist. The checklist included competency with skills list, administrative practice guidelines, medication administration, and reporting to Director of Nursing. The nursing staff should have competencies on wound care. The competencies could not be verified if there was no documentation. Annual competencies for Registered Nurses and Licensed Practical Nurses included hand washing, abuse, dressing change, medication administration, dementia care, oral care, and foot care. Additional training was based on current need, the statement of deficiencies, or community health issues. Orientation for all new hired nurses included general orientation and facility policies, then on the unit orientation. They had 2 medication administration

observations. If the medication administration observation was not acceptable, they would be re-trained.

During an interview on 7/2/2024 at 8:34 AM, Assistant Director of Nursing #25 stated they had observed competencies before the facility changed ownership.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 During an interview on 7/3/2024 at 10:33 AM, Licensed Practical Nurse #87 stated they wished the facility did more education, the educations they received recently due to the Immediate Jeopardy were helpful. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/8/2024 at 1:00 PM, Registered Nurse Unit Manager #94 stated they were observed

during a medication administration by their preceptor Licensed Practical Nurse #64. They were not educated Residents Affected - Many on respiratory equipment in the facility but knew how to provide care from previous experience and had 8 residents that required respiratory services. They did not received education regarding orders, they knew what to do with the medical orders.

During an interview on 7/8/2024 at 1:23 PM, Licensed Practical Nurse #28 stated they did not receive weekly education. They received education for medication administration but had never been observed doing medication administration. They had never seen anyone doing medication administration or hand hygiene

observations on the unit. They received education for wound care prevention in a classroom setting but had never been observed doing wound care.

During an interview on 7/8/2024 at 2:01 PM, Licensed Practical Nurse Unit Manager #2 stated they had ongoing education monthly for approximately 1 hour.

During an interview on 7/8/2024 at 2:44 PM, Licensed Practical Nurse #87 stated they had not completed medication administration competency since their orientation, and the facility did not complete medication administration competencies annually. They had not received any education regarding physician orders.

During an interview on 7/8/2024 at 3:15 PM, Registered Nurse #89 stated they did not have weekly education. They had a day 1 orientation, but only completed part of it as they were taken to the unit for supervisor and management specific training. That training included a walkaround of the unit, and how to organize their day by the outgoing manager. They were never observed completing medication administration or wound care. They stated that wound care and medication administration was not part of their job as the Registered Nurse Supervisor, or Registered Nurse Unit Manager. Although, they did remove and replace dressings based on the order when as part of the admission assessment.

During an interview on 7/10/2024 at 12:56 PM, Licensed Practical Nurse #102 stated they had worked in the facility for 3 days. They stated they completed day 1 general orientation, on day 2 someone showed them around the unit, and then they were put on a medication cart by themselves. On 7/10/2024, they were on a different unit running a medication cart by themselves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 During an interview on 7/10/2024 at 1:59 PM, Assistant Director of Nursing/Nurse Educator #27 stated competencies and annual mandatories were required by regulation. Annual competencies for nurses Level of Harm - Minimal harm or included hand washing, medication administration, wound care, and abuse education. If a nurse was to potential for actual harm provide medications, there should be a medication administration observation in their file. If a nurse was to do wound care, they would have a competency for wound care in the same folder with the medication Residents Affected - Many administration. A Registered Nurse completed the competencies. To ensure the competencies and education matched what the resident needs were identified as in the facility assessment, the corporate team provided Assistant Director of Nursing/Nurse Educator #27 what they needed. They were currently working

on gaps in tracking all the staff education and working with the Quality Assurance Committee to fix it. If staff needed remediation they would discipline or educate depending on the staff member. If there was a medication error, they would provide a pre-test, do education, and then the post-test. They would also observe the medication administration to ensure competency and document on the lesson plan for that person. They were responsible for grading the post-test but had assistance this month due to the additional educations. The answer key for the tests came from Corporate. A grade less than 85% would require re-education and staff would be tested again. During Licensed Practical Nurse #33's first medication administration observation, they did not clean the glucometer and it was identified for re-education. On the second medication administration observation, the glucometer observation was marked as not observed, as

the residents they were working with did not need the glucometer. Assistant Director of Nursing/Nurse Educator #27 stated they would go back and ensure they observed it was done correctly. On the post-test, Licensed Practical Nurse #33, scored 100% correct. Assistant Director of Nursing/Nurse Educator #27 reviewed Licensed Practical Nurse #33's quiz. Hypertension did not mean high body temperature, it meant high blood pressure, and Levodopa was not a medication given for mental depression. Assistant Director of Nursing/Nurse Educator #27 stated the questions and answers were not accurate, and the next steps would be to talk to the staff member, educate them, and ensure they understood the information provided to them. There was a new Licensed Practical Nurse #102 working the cart, but Assistant Director of Nursing/Nurse Educator #27 did not know who provided her medication administration and competency training as they had not received their paperwork yet. It was important to have professionally trained, competent nursing staff to ensure residents were cared for properly.

During an interview with the Administrator and Director of Nursing on 7/11/2024 at 8:52 AM, the Director of Nursing stated the importance of having trained competent nursing staff was to ensure staff could give safe and quality care to the residents. The lack of competent staff negatively impacted their quality assurance.

The Administrator stated they ensured staff was educated with the use of a very good orientation process with each Department Head presenting what was important to their department. Education focus was based

on the plan of corrections with policy and procedures updates. The process for maintaining proper record of training was a work in progress and was not perfect.

10 NYCRR 415.26(c)(1)(iv)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Immediate 48052 jeopardy to resident health or safety Based on observation, interview, and record review during the extended recertification and abbreviated (NY0033160) surveys conducted 6/4/2024-7/11/2024, the facility failed to provide medically related social Residents Affected - Some services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 of 5 residents (Resident #41, #126, #153, #235, and #250) reviewed.

Specifically:

- Resident #41 had an extensive mental health history, did not have person-centered mental health interventions, and was seen by a licensed psychologist and their recommendations were not implemented into the resident's plan of care. There were no documented social services follow ups with the resident following their behaviors.

- Resident #126 had a significant mental health history and did not have person-centered mental health interventions for their behaviors or refusals of care and medications. There were no documented social services follow ups with the resident following their behaviors.

- Resident #153 was seen by a licensed psychologist and their recommendations were not implemented into

the resident's plan of care, a recommendation for a traumatic brain injury program was not investigated, and recommendations to continue psychotherapy were not followed. There were no documented social services follow ups with the resident following their behaviors.

- Resident #235 had behaviors of taking things off the nurses' cart and throwing them leading up to an episode of threatening staff with scissors, requiring police intervention and hospitalization for the resident. There were no documented interventions from social services and the resident did not have person-centered interventions for their history of delusions and taking/throwing things off the nurses' cart.

- Resident #250 had an extensive mental health history including paranoid schizophrenia and did not have person-centered mental health interventions for their behavioral symptoms.

This placed all residents with mental health disorders at risk for physical, mental, and psychosocial harm that was Immediate Jeopardy and Substandard Quality of Care.

Findings Included:

The facility policy, Behavior Management revised 5/2020, documented the facility provided an interdisciplinary approach for the care of residents who exhibited problem behavioral symptoms which could lead to negative consequences for themselves or others. Residents who demonstrated changes in behavior would be evaluated to ensure appropriate interventions, as needed, were instituted in a timely manner. A resident's behavioral symptoms and approaches would be placed in the resident-specific plan of care and communicated to care staff and other departments as appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 The facility policy, Care Plans- Comprehensive revised 10/2019, documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's Level of Harm - Immediate physical, psychosocial, and functional needs was developed and implemented for each resident. The jeopardy to resident health or identification of problem areas and their causes and developing interventions that were targeted and safety meaningful to the resident, was the goal of the interdisciplinary process. The interdisciplinary team reviewed and updated the care plan quarterly, when a significant change occurred, when a desired outcome was not Residents Affected - Some met, and when a resident was readmitted from a hospital stay.

The facility policy, Social Services revised 10/2019, documented the facility provided medically related social services to assure each resident can attain or maintain their practicable physical, mental, or psychosocial well-being.

1) Resident #41 had diagnoses including schizoaffective disorder (a mental health condition with a mix of schizophrenia symptoms and mood disorder symptoms), anxiety, and depression. The 4/27/2024 Minimum Data Set assessment (a health status assessment tool) documented the resident had severely impaired cognition, had no behavioral symptoms in the 7-day look back period, was independent with most activities of daily living, had a diagnosis of schizophrenia disorder (schizoaffective and schizophreniform disorders), anxiety, and depression and was taking an antidepressant and an antipsychotic medication daily.

The 4/29/2024 Comprehensive Care Plan documented the resident utilized psychotropic medication related to schizoaffective disorder, anxiety, and depression with hallucinations and psychosis. Interventions included to give medications as ordered, monitor and record target behaviors and potential side effects, and have psychiatry and psychology consults as needed. There were no documented person-centered interventions.

A 1/7/2024 at 1:03 PM Licensed Practical Nurse #66's progress note documented the resident told them they were leaving. They notified the Supervisor who came to the unit and spoke to the resident. The Supervisor told Licensed Practical Nurse #66 if the resident attempted to leave to not attempt to stop them and let the Supervisor know. At 12:52 PM the resident came into the main hallway with two garbage bags full of items and started walking toward the elevator. The Supervisor was called. The resident got on the elevator and the doors closed.

A 1/7/2024 at 2:00 PM Registered Nurse Supervisor #19's progress note documented the resident cut off their wander alert device and took the elevator to leave the facility. Emergency Medical Services and the police department was called due to the resident's attempt at an unsafe discharge. The resident's Health Care Proxy was called and agreed to transfer the resident to the hospital. The resident was sent to the hospital for psychiatric evaluation.

The 1/7/2024 hospital after visit summary documented the resident was seen for a mental health problem with a diagnosis of difficulty controlling their anger. General information on managing anger was provided in

the form of a paper hand out with directions to go to the comprehensive psychiatric emergency program if symptoms worsened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 The 1/9/2024 Licensed Psychologist #36 progress note documented the resident had depression, schizoaffective disorder, and adjustment disorder. The resident felt angry, defiant, frustrated, and Level of Harm - Immediate overwhelmed. The resident stated they had been taken to the hospital for crisis management and was angry jeopardy to resident health or with the interaction. They had difficulty with reality testing during the session and stated they would live in the safety woods with the animals like they had in the past when they had been raised by bears. The resident stated

they would commit suicide by cop if they were engaged by law enforcement again to be forced to go to the Residents Affected - Some hospital. The Registered Nurse Manager and nurse practitioner were informed of the statement and to be aware of the intention of aggression if confronted by law enforcement. The facility nurse practitioner was looking to coordinate a transfer to a more intense psychiatric program. The plan included to continue with psychotherapy and to follow up with therapy as scheduled. The recommendation was to continue with supportive care, safety precautions per facility policy, monitoring for mood, behavior, and sleep, redirect as clinically indicated, and to continue with psychotherapy. The resident remained with altered mental status and psychosis and had been highly agitated. Approach the resident with empathy and nonthreatening language and behavior. An escalation of conflict would result in a negative outcome and the resident should be provided with space, a soft voice, and a nonthreatening tone.

There was no documented evidence the resident's Comprehensive Care Plan was updated to include the recommendations from Licensed Psychologist #36.

The 1/18/2024 Licensed Psychologist #36 progress note documented the resident was angry, blaming, and edgy/irritable. The resident was angry and felt trapped in the facility. This triggered the resident's history of being abused and resulted in aggressive behavior for self-defense and survival. The resident was provided with reflective listening, disarming, and thought/feeling empathy and the resident was agitated but responsive. The recommendation was the same as the 1/9/2024 psychotherapy progress note.

There was no documented evidence the resident's Comprehensive Care Plan was updated to include the recommendations from Licensed Psychologist #36.

The 1/29/2024 Chief Medical Officer #11's progress note documented the resident had removed their wander alert device over the weekend and was brought back by police. The resident was actively threatening to kill themselves without a specific plan. They were also threatening to harm other individuals but did not state who the intent was directed at. The licensed psychologist was present during the visit. The resident had not been taking their antipsychotic medication. The resident was sitting in their chair physically shaking their hands which appeared to be extremely aggressive movements. The resident was threatening to harm themself and everyone around them. 911 was notified with police back up. The resident was deemed a risk to themselves and other residents in the facility. After much discussion they were able to get the resident to voluntarily go to the hospital.

The 1/29/2024 hospital after visit summary documented the resident had been seen for homicidal, suicidal, and aggressive behavior with diagnoses of suicidal thoughts and aggressive behavior. The resident had been cleared by psychiatry prior to discharge with a recommendation to follow-up with outpatient providers as necessary.

There was no documented evidence the comprehensive care plan was revised to reflect suicidal and homicidal ideations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 A 2/10/2024 at 12:00 PM Licensed Practical Nurse #31's progress note documented the resident was threatening staff stating if a certain nurse was not there to help them, the resident would harm the staff. The Level of Harm - Immediate resident began swinging at the staff providing 1:1. jeopardy to resident health or safety A 3/20/2024 Licensed Psychologist #36 progress note documented the resident was angry, and ranted and vented their dislike and distrust. The did not want to be in long term care. The resident seemed interested in Residents Affected - Some treatment, was motivated, shared appropriate thought process and seemed to benefit from the session. Recommendations included continue psychotherapy as scheduled, supportive care, safety precautions, monitoring mood/behavior/sleep, and redirect as clinically indicated. Those approaching the resident should use empathy and non-threatening language and behavior. Escalation of conflict would result in negative outcomes. The resident would be seen by the clinician in 1-2 weeks.

There was no documented evidence of follow-up in 1-2 weeks by Licensed Psychologist #36 after the 3/20/2024 consultation.

The 6/4/2024 comprehensive care plan documented the resident had behavioral symptoms such as refusals of medications for auditory and visual hallucinations. Interventions included to determine the cause and maintain the resident's safety, initiate psychiatric and psychology evaluation as needed, praise and reinforce appropriate behavior, and for certified nurse aides to monitor behavior symptoms as needed. There was no documentation of what interventions to implement when behavioral symptoms occurred or of the resident's history of homicidal and suicidal ideations, aggressive behavior, or history/verbal statements of planned combativeness when law enforcement was called.

During an interview on 6/11/2024 at 11:15 AM, Social Worker #37 stated social work was responsible for the care plans that involved mental health and behavioral symptoms. Care plans were updated quarterly, for a significant change, and as needed when issues came up. If a resident had specific behaviors, they should be included in the plan of care. If a resident was on psychotropic medications, their behaviors would be in the interventions on the care plan. If a resident exhibited their target behaviors, staff should report those behaviors to the physician, see if there were any as needed medication that could be given, and contact the psychologist or psychiatrist. They did not list immediate specific interventions for staff to implement when a behavior occurred, but they should as the care plan was meant to be person-centered. Resident #41's behaviors were not care planned with specific interventions but should have been. There should be a care plan for a resident who had homicidal and suicidal ideations. They stated they were not aware Resident #41 had a history of homicidal and suicidal ideations.

During an interview on 6/11/2024 at 11:59 AM, the Director of Social Work stated residents' behaviors should be documented on their plan of care. The resident should also have specific interventions for their behaviors. What worked for one resident may not work for another. The staff would know what interventions to implement for the resident by looking at their plan of care. If a resident had a history of suicidal ideations and homicidal ideations it should be on the plan of care.

During an interview on 6/12/2024 at 10:20 AM, Resident #41 stated they did not like doing mental health appointments over the phone or via telehealth. They stated they did not like to talk to a screen so would refuse if that was offered. They stated they did participate with Licensed Psychologist #36 because they came in person to talk to them. The resident stated they had a history with their mental health which included mental health inpatient stays related to messing up their medications and being involved with a treatment team when they were living in the community.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 During an interview on 6/12/2024 at 10:33 AM, Licensed Psychologist #36 stated they had seen Resident #41 in May 2024 and June 2024 but there was a period where the resident was avoiding visits by pretending Level of Harm - Immediate to sleep. When the resident started to become more involved in physical therapy and going out with their jeopardy to resident health or adult child, so they were unable to see them. They expected their recommendations for approaches and safety interventions for behaviors to be included in the resident's plan of care. They stated the resident's verbalization about committing suicide by cop and the need to let law enforcement knows the resident would Residents Affected - Some react aggressively to law enforcement should be on their plan of care so that someone not familiar with the resident would be aware should the police need to be called.

During an interview on 6/12/2024 at 12:26 PM, Nurse Practitioner #22 stated the resident had exacerbations of their schizoaffective disorder with psychotic features where they were aggressive towards staff and threatened to harm themself. They sent the resident to the hospital multiple times for being a danger to themself and others. When the resident got bad, they could not be controlled in this setting and had to be sent out. Recently, the resident's behaviors had been controlled but the resident had a history of ups and downs. Any behavioral approach recommendation from Licensed Psychologist #36 should be on the resident's plan of care. They stated specific non-pharmacological interventions for behaviors should be on

the plan of care.

During an interview on 6/12/2024 at 12:46 PM, Chief Medical Officer #11 stated if Licensed Psychologist #36 made any recommendations for behavioral health they needed to be known by the resident's direct care staff and should be on the care plan.

2) Resident #153 had diagnoses including intracranial injury with loss of consciousness (brain injury), major depressive disorder, hydrocephalus (fluid buildup in the brain that causes brain swelling), and vascular dementia. The 5/17/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had verbal behavioral symptoms directed towards, rejected care, and wandered 1-3 of 7 days, was independent with activities of daily living, and took antipsychotic and antidepressant medication routinely.

The 3/2/2023 physician order documented to monitor for behaviors: itching, picking at skin, restlessness, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusion, hallucinations, psychosis, aggression, and refusing care.

The comprehensive care plan initiated 5/3/2022 documented the resident exhibited behavior of wandering through out the unit taking items off the nurses' station desk, taking staff and resident food from fridge, entering other residents' rooms, and taking personal items belonging to others, episodes of socially inappropriate behaviors, and episodes of verbally aggressive behavior. The interventions were to check for thirst and hunger, distract resident with preferred activity, initiate psychiatric and psychology evaluation as needed, modify the environment to reduce episodes of behavior, and to redirect negative behavior as needed.

The Psychiatric Mental Health Nurse Practitioner #91 recommended the resident would benefit from talk therapy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 The 3/20/2024 Licensed Psychologist #36 progress note documented the resident had been aggressive to staff as well as peers. The recommendations included to continue supportive care, continue with safety Level of Harm - Immediate precautions per facility protocol, continue monitoring for mood, behavior, and sleep, to redirect as clinically jeopardy to resident health or indicated, and to continue with psychotherapy. The resident would be provided with psychotherapy 1-3 times safety per month to assist with monitoring of mood and behavior. The goal was to work to reduce aggressive behavior, improve coping skills for boredom, work on acceptance of circumstances, and increase prosocial Residents Affected - Some skills. The resident would benefit from the investigation of a traumatic brain injury program that allows for more activity and behavioral support, possible community-based integration with supervision.

There was no documented evidence a traumatic brain injury program was explored as recommended.

The resident had no documented psychotherapy notes after 3/20/2024.

The 6/11/2024 Psychiatric Mental Health Nurse Practitioner #73 documented the resident had increased wandering at night, intermittent medication refusals, and verbal aggression toward staff.

There was no documented evidence of social work progress notes related to the resident's behaviors or increased wandering.

During an observation on 6/24/2024 at 4:44 PM The resident was standing up and was acting verbally aggressive toward the nurse. The resident stated, I am going to go in everyone room, grab hold of them. The nurse was documenting on a computer and the resident pointed toward the surveyor and said, she don't know me, thinks I am a sucker.

The June 2024 treatment administration record documented monitor for behaviors: itching, picking at skin, restlessness, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusion, hallucinations, psychosis, aggression, and refusing care. Document Y if monitored and none of the above were observed. Document N if monitored and any of the above was observed, and document in progress notes as Behavior note every shift. The behaviors had documented check marks with no Y or N from 6/1/2024-6/26/2024 (12 of 78 opportunities for documentation were blank).

Nursing notes from 6/1/2024-6/26/2024 documented:

- 6/4/2024 at 12:42 by Licensed Practical Nurse #34 PM refused all meds.

- 6/9/2024 at 2:18 PM by Licensed Practical Nurse #98, the resident refused medications after three attempts and stated. I ain't takin' that [expletive], why you standin' there watching me, like I won't knock you out. Continued to approach staff and residents stating, I've been fighting my whole life, I'll knock your ass out. Redirection was unsuccessful.

- 6/11/2024 at 3:50 AM by Licensed Practical Nurse #99 resident found standing next to another resident's bed looking at them, redirection was attempted, and the resident became verbally abusive when redirected.

- 6/11/2024 at 4:55 AM by Registered Nurse Supervisor #89 aware of resident entering another resident's room. Reminded staff to complete behavior notes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 - 6/17/2024 at 1:17 PM by Licensed Practical Nurse #98 attempted to administer medications three times. Resident refused stating they were tired of this [expletive]. Level of Harm - Immediate jeopardy to resident health or - 6/20/2024 at 1:00 PM by Registered Nurse Unit Manager #94 refused medication after numerous attempts. safety Resident then went outside with a certified nurse aide.

Residents Affected - Some - 6/24/2024 at 12:07 PM by Licensed Practical Nurse #98 Resident held medications in their hands for 30 minutes before placing them in their mouth. Resident continuously stated, I've been fighting my whole life, I'll [expletive] your ass up. The resident held the medications in their mouth for 30 minutes before swallowing.

There was no documented evidence the social worker or physician was aware of the resident's behavioral symptoms in 6/2024.

During an observation on 6/26/24 at 10:03 AM, the resident was in their room sitting on the edge of bed, dressed, no sneakers on, wrapped in a sheet, wiggling their right leg, and twisting the sheet.

During an interview on 6/27/2024 at 11:06 AM, Licensed Psychologist #36 stated they saw the resident on 4/11/2024 in addition to their initial visit on 3/20/2024. They stated the recommendations from their psychotherapy note included a traumatic brain injury program that allowed for more activity and behavioral support for the resident as well as possible community integration. The resident had hydrocephaly and when

the shunt became blocked, the resident's behavior could change significantly. The resident would benefit from the traumatic brain injury program as it would be more specialized care and would assist with behavior management. The resident was young, bored, and was triggered easily. The resident felt very trapped but also cognitively lacked clarity and did not understand their processes.

During an interview 6/26/2024 1:35 PM, the Director of Social Work stated they reviewed Licensed Psychologist #36's notes after they were completed, and they also received a synopsis of the visits via email from the provider. They were unaware if the resident had been seen since the initial visit in March 2024.

They did not think the recommendation for a traumatic brain injury program was followed up on. The social workers should meet with residents who are having behaviors or increased behaviors.

During an interview on 6/27/2024 at 2:36 PM, Nurse Practitioner #22 stated the resident's behaviors were related to their traumatic brain injury and hydrocephaly; especially if the shunt for their hydrocephaly was blocked. The resident's nature was if you said hello to them, they would respond with I'm going to punch you.

They did not believe the resident to be an immediate threat, but they had the potential. They had to move the resident depending on the nature of the patient population of the floor the resident was on. They did believe

the recommendation for a traumatic brain injury program to assist with boredom and behaviors would be good for the resident due to need for more specialized care. A community outpatient program could be beneficial to assist the resident. They believed the resident needed more than they were getting in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 3) Resident #235 had diagnoses including unspecified dementia without behavioral disturbance and major depressive disorder. The 3/28/2024 Minimum Data Set assessment documented the resident had Level of Harm - Immediate moderately impaired cognition with disorganized thinking and inattention, had mild depression, had a jeopardy to resident health or diagnosis of non-Alzheimer's dementia and depression, and received antipsychotic and antidepressant safety medication routinely.

Residents Affected - Some The comprehensive care plan initiated 4/1/2023 documented the resident had a potential for resident-to-resident altercation as evidenced by aggression, hitting, slapping, throwing objects, yelling, and using foul language. Interventions included administer medications, identify environmental triggers, maintain visual line of sight, monitor behavior and document, notify medical doctor of negative behavior, offer diversional activity, refer to psychiatry/psychology services, and separate from the aggressor/victim. The resident exhibited behavior symptoms such as aggressiveness and danger to other due to cognitive impairment. 2/18/204, the resident attempted to stab at staff with sharp scissors. Additional interventions included to send the resident to the hospital for psychological and medication evaluation due aggressiveness, attempt to hurt others, brandishing a weapon (scissors), and danger to self and others.

Nursing notes documented:

- on 2/13/2024 at 3:16 PM by Licensed Practical Nurse #86 the resident was extremely agitated and confused and repeatedly threw items from the nursing cart and screamed for the State Police to be called.

The resident was difficult to redirect. The Supervisor and Unit Manager were notified.

- on 2/18/2024 at 7:49 PM by Registered Nurse #18 the licensed practical nurse reported the resident was extremely agitated and confused and repeatedly threw items from the nursing cart and called for the State Police to be called. Telemedicine was called and an order for Haldol (antipsychotic) 5 milligrams/milliliter inject intramuscularly one time only for aggressive behavior. Obtain a stat (immediate) urinalysis for possible urinary tract infection.

- on 2/19/2024 at 2:20 AM by Registered Nurse Unit Manager #23 the resident was threatening staff with a pair of scissors and lunged at staff in a threatening manner. They attempted to retrieve the scissors and the resident tried to swipe at all staff who attempted. Resident was making delusional statements, was offered, and refused oral Haldol stating there was arsenic in it. Emergency Medical Services was called. Staff was told to stay away from the resident for safety, police arrived and requested the scissors, and the resident threw the scissors at the officer and the scissors landed on the floor. The resident was sent out of the facility for psychiatric evaluation.

The 2/19/2024 hospital after visit summary documented the resident was seen for a psychiatric evaluation, had a diagnosis of dementia with behavioral disturbance, and was provided with an antipsychotic at the hospital.

The 2/21/24 initial psychiatric evaluation by Psychiatric Mental Health Nurse Practitioner #73 documented

the resident had an incident on 2/19/2024 when the resident was threatening staff with a sharp pair of scissors and trying to lunge at staff. They also had increased paranoia and refusing medications due to the belief they had arsenic. There was a concern the resident was not taking their medications and was spitting them out which the resident's adult child stated they had a history of. They recommended to decrease the environmental stimuli, ensure all needs were met, and implement behavior interventions such as distraction measures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 There was no documented evidence the care plan was updated with the recommendations from the Psychiatric Mental Health Nurse Practitioner #73. Level of Harm - Immediate jeopardy to resident health or There were no nursing progress notes on 3/31/2024 documenting the resident had behaviors or was sent to safety the hospital.

Residents Affected - Some The 3/31/2024 hospital after visit summary documented the resident was seen for aggressive behavior, had

a diagnosis of dementia of unspecified type whether behavioral, psychotic, or mood disturbance, or anxiety, and was provided with psychotropic medication at the hospital.

There were no documented social services progress notes in relation to the resident's increased behaviors or emergency department visits for psychiatric evaluation or aggressive behavior.

During an interview on 6/26/2024 at 11:40 AM, Social Worker #92 stated the social worker's role if a resident was having behaviors was to try to find interventions for the resident and put them in their plan of care. The plan of care identified the resident's behaviors and the interventions to meet the stated goal. The plan of care should be personalized for each resident. Any interaction with the resident should be documented. If a resident had a change in condition or increased behaviors, they would make a referral for either psychiatry or psychology. If they noticed a change, they would speak with nursing to see if the change was new or if a referral had gone in. They believed Resident #235 had a personalized plan of care. 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. If a resident's behaviors were resolved, they should be removed from the plan of care. They did not include the resident's history of behaviors on their plan of care.

During an interview on 6/26/2024 at 1:35 PM, the Director of Social Work stated if a resident went to the emergency department for psychiatric reasons, the social worker should check on them when they returned. Care plans were not only for active behaviors. If someone has not had a behavior in a while, the care plan could be changed to state a history of so the information was not completely gone and there was a trail.

During a follow up interview on 7/02/2024 at 1:24 PM, they stated an intervention that documented to provide distraction measures was not personalized as it should include what the distractions were.

During an interview on 6/27/2024 at 2:36 PM, Licensed Psychologist #36 stated they had seen the resident and was unsure why their psychotherapy notes were not in the electronic medical record. They stated the resident was referred for psychotherapy services after their emergency department visits in February 2024 and March 2024 for mental health. Their recommendation was to monitor the resident and continue supportive care as their dementia was progressing. The resident's family visited, and the resident did well with that. The resident really enjoyed visiting and was easily redirected.

10 NYCRR 483.40 (d)

________________________________________________________________

Immediate Jeopardy was identified, and the Administrator was notified on 6/27/2024 at 4:00 PM. Immediate Jeopardy was removed on 7/03/2024 at 11:43 AM prior to survey exit based on the following corrective actions taken.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 -100% of social work department staff had been educated on medically related social services.

Level of Harm - Immediate -Post-tests were reviewed. jeopardy to resident health or safety -Staff education sign in sheets were reviewed and compared to the current social work staff list and no discrepancies were identified. Residents Affected - Some -Staff education was verified during an onsite visit on 7/1/2024, all social work department staff were interviewed to determine retention of education provided and were able to accurately report content of the education.

-All five identified residents resident records were reviewed, and documentation reflected each had a social work assessment completed.

-All five identified resident plans of care were reviewed and had updated person-centered interventions for their mental health.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 44838

Residents Affected - Many Based on observation, record review, and interview during the extended recertification survey conducted 6/4/2024-7/11/2024, the facility did not ensure the licensed pharmacist reviewed resident medication regimens and medical records to identify and report irregularities and act upon reported irregularities to minimize or prevent adverse consequences. Specifically, Resident #147 had physician orders for heparin (a blood thinner) and insulin (a medication to lower blood sugar) that were consistently documented as refused

on the Medication Administration Record, and there was no documented evidence the Medication Administration Record was reviewed during the monthly medication regimen review (a thorough evaluation of

the medication regimen of a resident, including review of the medical record to prevent, identify, report, and resolve medication-related problems or other irregularities) by the licensed pharmacist.

Findings include:

The facility policy Medication Regimen Reviews, last revised 11/2021 documented the goal of the medication regimen review was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The medication regimen review involved a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors and other irregularities. The medication regimen and associated treatment goals involved collaboration with the resident (or representative), family members, and the interdisciplinary team. As such, the medication regimen review included a review of the resident's (or representative's) stated preferences, the comprehensive care plans, and information provided about the risks and benefits of the medication regimen.

Resident #147 had diagnoses including diabetes mellitus type 1 (the body does not make insulin) and end stage renal disease (kidney disease) requiring hemodialysis (a treatment to filter the blood of toxins). The 3/30/2024 Minimum Data Set assessment (health assessment screening tool) documented the resident had intact cognition, had no behavioral symptoms, did not reject care, required set up assistance or supervision for activities of daily living, and received one insulin injection in the previous 7 days and received an anticoagulant in the last 7 days.

The 1/2/2024 physician orders documented heparin sodium injection solution 5000 units per milliliter, inject 1 milliliter subcutaneously 3 times daily for blood clot prevention (discontinued 6/26/2024), insulin lispro (a fast-acting insulin) inject as per sliding scale (the amount of insulin administered is based on the results of

the blood glucose finger sticks) subcutaneously before meals for diabetes mellitus.

The 1/2024- 6/2024 Medication Administration Records documented the resident received heparin on 6/3/2024 at 8:00 PM and on 6/23/2024 at 2:00 PM and 8:00 PM. All other scheduled doses during that time were not given due to documented resident refusal or the resident was out of the facility. The resident received blood glucose monitoring and was administered sliding scale insulin zero times in 1/2024, twice in 2/2024, 5 times in 3/2024, twice in 4/2024, zero times in 5/2024, and 9 times in 6/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 The comprehensive care plan documented the following:

Level of Harm - Minimal harm or - initiated on 4/28/2022 documented the resident had a history of exhibiting behavior symptoms such as potential for actual harm verbal aggression, combativeness, and refusing dialysis and care. Interventions included notify physician of new or escalating behavior, with updates on 6/21/2024 to reapproach resident for care/toileting/medication Residents Affected - Many administration/treatments and other needs when resident was more agreeable; refuses medications.

- initiated on 8/15/20202 documented the resident had Insulin dependent diabetes mellitus with intervention to administer medications per physician orders and monitor blood glucose finger stick per physician orders.

- initiated on 10/3/2022 documented the resident was at risk for bleeding secondary to non-steroidal anti-inflammatory drugs/anticoagulant use prophylaxis. Interventions were to administer medications as prescribed and monitor effectiveness of medications given and observe for adverse reactions.

Drug regimen reviews completed by pharmacists #92 and #93 on 1/3/2024, 1/31/2024, 2/28/2024, 3/31/2024, 4/30/2024, 5/31/2024, and 6/30/2024 documented no recommendations. There was no mention of missed or refused medications in the reviews.

During an interview on 6/27/2024 at 10:38 AM, Licensed Pharmacist #92 (Licensed Pharmacist #93 was unavailable for interview) stated pharmacy reviews were performed as federally mandated. They did drug regimen reviews for the facility on admission, monthly, and for any significant changes. Reviews were done remotely using the electronic health record. They checked resident allergies, all medications for dosing according to standard of practice, ensured no duplication of therapy, checked for laboratory values being done appropriately, and psychotropic medications being reevaluated for use. All medications need clinical indications and appropriate diagnosis. They stated they did not look at medication administration records unless looking at as needed use. If a resident was refusing medications and it was brought to their attention, or if they were aware of refusals, they would notify the prescriber and provide options. The most important thing was notification of the provider. They ensured heparin was being received with appropriate diagnosis, dosing per standards of practice, and lab monitoring. The sliding scale insulin should be limited if possible.

They reviewed records for diabetic medications being used and reviewed values of glucose monitoring. Refusal of medications were not included on the pharmacy recommendations as the nurses should notify the medical providers of medication refusals. The medical provider should be made aware of refusals, and it was their responsibility to come up with a plan. As a pharmacist their scope was limited and would only make suggestions for alternatives when asked. If the refusals of medications had been noticed, they would notify

the physician. A resident who did not receive prescribed heparin could be at increased risk for a blood clot, deep vein thrombosis, atrial fibrillation, pulmonary embolism, or a stroke. The physician should have been made aware of the refusal of insulin and blood glucose monitoring due to increased risk of hyperglycemia or hypoglycemia. The pharmacist did not feel pharmacy was responsible for notifying the providers and that nursing should be making medical providers aware of medication refusals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 During an interview on 6/28/2024 at 9:21 AM, the Director of Nursing stated the medication regimen reviews were done remotely. They should include review of all medications, and appropriate clinical indications. The Level of Harm - Minimal harm or pharmacists reviewed the resident electronic health record, and they had access to the medication potential for actual harm administration record. It was expected that any medication irregularities were reported. Consistent medication refusals would be considered an irregularity. The medical provider should have been made Residents Affected - Many aware of the resident consistent medication refusals. The team had several conversations regarding Resident #147's refusals but had not documented this in the record.

During an interview on 6/28/2024 at 9:42 AM, the Medical Director stated the medication regimen review should be to review medications for reasonability, clinical indication, and make sure that medication levels were obtained as needed. They were not sure if the pharmacist looked at the medication administration record. Medications not being received should be reported to the medical provider. They were not aware Resident #147 had not been receiving medications as ordered. Not receiving heparin could lead to stroke, pulmonary embolism, or blood clots. The risk for not receiving insulin as ordered was blood sugars out of control.

10 CRRNY 415.18 (c)(2)

48895

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 48446 Residents Affected - Some 48895

Based on observation, interview, and record review during the extended recertification survey conducted 6/4/2024-7/11/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions when applicable for 2 of 11 medication carts (A Unit-Cart 1 and 4th floor low side cart) and for 3 of 9 medication rooms (A unit, 3rd floor, and 4th floor) reviewed. Specifically,

- the A unit cart 1 medication cart contained 1 insulin pen without the date it was opened, and the medication room refrigerator was outside of an acceptable temperature range at 28 degrees Fahrenheit, with a white fuzzy substance on the inside back wall.

- the 4th floor low side medication cart contained 1 insulin pen that was expired, and the medication room refrigerator was outside of an acceptable temperature range, at 30 degrees Fahrenheit.

- the 3rd floor medication room refrigerator was outside of an acceptable temperature range at 62 degrees Fahrenheit.

Findings include:

The facility policy, Insulin Administration, dated 1/2020, documented insulin expiration dates would be checked. If opening a new vial, record the expiration date and time on the vial, following manufacturer recommendations for expiration after opening.

The facility policy, Medication - Storage, dated 1/2019 documented expired, discontinued, and/or contaminated medications would be removed from the medication storage areas and disposed of in accordance with facility policy. Medication requiring refrigeration would be stored in a refrigerator that was maintained between 36 and 46 degrees Fahrenheit. The temperature would be checked daily to ensure it was within the specified range. If the temperature was out of range, the refrigerator thermostat would be adjusted.

Manufacturer instructions for NovoLog (insulin aspart) and Lantus (insulin glargine) documented to dispose of the insulin after 28 days, even if there was insulin remaining in the pen or vial. Unused NovoLog pens and vials should be stored between 36 and 46 degrees Fahrenheit until expiration.

A unit:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During an observation of the medication cart on 6/5/2024 at 2:38 PM with Licensed Practical Nurse #28, a Lantus Solostar (insulin) pen for Resident #106 was not labeled with the date it was opened. Licensed Level of Harm - Minimal harm or Practical Nurse #28 confirmed the insulin pen had been opened and did not have an opened-on date listed. potential for actual harm They stated Lantus (insulin) was good for 28 days. If there was no opened date listed, there was no way to tell if the insulin was good, and expired insulin might not be effective. Residents Affected - Some

During an observation on 6/5/2024 at 2:50 PM with Licensed Practical Nurse #28, the temperature of the medication refrigerator was 28 degrees Fahrenheit and had a white fuzzy substance on the inside back wall. Licensed Practical Nurse #28 stated they did not know what the substance in the refrigerator was. The unit nurses were responsible for cleaning the refrigerator and the Maintenance Department was responsible for

the temperatures of the refrigerator.

During an interview on 6/7/2024 at 9:04 AM, Licensed Practical Nurse Unit Manager #2 stated the medication nurses were responsible for maintaining the medications in the cart. The nurse that opened the insulin was responsible for labeling the insulin pen with the open date. The pen should have been labeled. It was important as the insulin expired after 28 days, and the nurses could administer expired medications to a resident. The Unit Manager and the medication nurses were responsible for cleaning the inside of the medication refrigerator. They stated the white fuzzy substance appeared to be ice buildup inside of the refrigerator.

3rd Floor:

During an observation on 6/5/2024 at 2:10 PM with Licensed Practical Nurse #29, the 3rd floor medication room refrigerator was 62 degrees Fahrenheit. Licensed Practical Nurse #29 stated that was not good, and

the refrigerator temperatures should not be over 42 degrees Fahrenheit. If the temperature was over 42 degrees Fahrenheit the medications could go bad, as they needed to be refrigerated to keep their integrity.

During an interview on 6/10/2024 at 3:36 PM, Licensed Practical Nurse Unit Manager #13 stated maintenance checked the refrigerator temperatures. It was important to check the temperature as medications could lose their efficacy if not stored properly. The refrigerator should be between 35 and 39 degrees Fahrenheit. The refrigerator temperature was too high at 62 degrees Fahrenheit. The refrigerator was not plugged in, maintenance was called, and the refrigerator was now working. The insulin in the refrigerator was discarded, as it might not work properly.

4th Floor:

During an observation of the 4th floor medication cart on 6/5/2024 at 1:38 PM with Licensed Practical Nurse #4, a Novolog Flex pen (insulin aspart injection pen) for Resident #205 had an opened date of 4/20/2024. At 1:48 PM the medication room refrigerator temperature was 30 degrees Fahrenheit.

During an interview on 6/5/2024 at 1:48 PM Licensed Practical Nurse #4 stated insulin expired 30 days after opening and expired medication might not be as effective. The nurse that opened the insulin was responsible for labelling it with the open date. All nurses should check expiration dates when administering medications. Refrigerator temperatures were checked by the night shift nurses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During an interview on 6/5/2024 at 2:16 PM, Assistant Director of Nursing #24 stated expired medications might not be as effective. Insulin expired 28 days after opening. Insulin needed to have a date it was opened Level of Harm - Minimal harm or and labelled by the nurse that opened it. All nurses administering insulin should check the open date. The potential for actual harm refrigerator temperatures were checked by maintenance daily. The medication refrigerator temperature was 32 degrees Fahrenheit, and it was supposed to be between 36 and 46 degrees Fahrenheit. Medications had Residents Affected - Some to be stored in a temperature range to maintain their integrity.

During an interview on 6/11/2024 at 9:43 AM, Registered Nurse Infection Preventionist #27 stated there should not be anything on the back wall of the medication refrigerator. The white fuzzy substance could be mold and could contaminate the medications in the refrigerator.

During an interview on 6/11/2024 at 11:01 AM, Nurse Practitioner #22 stated that insulin should be labeled when opened, as once it was opened, the nurses had 28 days to use it. Insulin could lose its efficacy after 28 days.

During an interview on 6/11/2024 at 12:09 PM, Maintenance Staff #21 stated the maintenance department was responsible for checking the refrigerator temperature and manually adjusting the temperatures to maintain them between 36 and 46 degrees Fahrenheit. The medication refrigerators had a manual dial inside to adjust if the refrigerator was out of temperature range. If the refrigerator remained out of temperature range after adjustment the department would order a new one. The unit staff was responsible for cleaning

the refrigerator and for the items in the refrigerator.

10 NYCRR 415.18(d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34465 safety Based on record review and interview during the extended recertification and abbreviated (NY00335379) Residents Affected - Some surveys conducted 6/4/2024-7/11/2024, the facility failed to ensure the ordering physician was notified promptly when a laboratory result fell outside of clinical reference range for 3 of 3 residents (Residents #153, #260, and #529) reviewed. Specifically,

- Resident #529 had abnormal laboratory results including a high white blood cell count, a low lymphocyte count, and high sodium, blood urea nitrogen, and blood urea nitrogen/creatinine ratio (indicating possible dehydration and infection) that were not reviewed by facility staff in a timely manner, and the medical provider was not notified in a timely manner of the abnormal lab results. Subsequently, the resident was hospitalized 3 days later with pneumonia and dehydration.

- Resident #153 had a critically low blood glucose (blood sugar) of 49 milligrams/deciliter and the provider was not notified in a timely manner and the resident was not assessed.

- Resident #260 had a high international normalized ratio (INR, used to determine blood clotting times for residents on anticoagulant therapy) and the provider was not notified timely, and the resident was not assessed.

This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety.

Findings include:

The facility policy, Laboratory Services, revised 8/2019, documented the facility would provide or obtain laboratory services to meet the needs of its residents. Licensed staff would make appointments and arrangements with the facility's laboratory for all the resident's ordered laboratory tests, obtain specimens as needed, and promptly inform the resident's physician of all abnormal test results by phone or fax. When the physician responded, the response was to be documented in the resident's chart.

The facility policy, Anticoagulation Therapy, revised 3/2019, documented all residents would have labs drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. The physician would order appropriate lab testing to monitor anticoagulant therapy. Staff could use a warfarin flow sheet or comparable monitoring tool to follow trends in anticoagulant dosage and response. The policy did not include directions for communication of lab testing results to the physician.

The electronic medical record Lab Results report documented a legend for flags included on the report. A red stop sign with an exclamation mark in the center indicated the report contained critical results (results in red text). A yellow triangle with an exclamation mark in the center indicated the report contained abnormal results (results with orange text).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 1) Resident #529 had diagnoses including dementia, malnutrition, and peripheral vascular disease (poor circulation). The 1/26/2024 Minimum Data Set assessment (a health status assessment tool) documented Level of Harm - Immediate the resident had severely impaired cognition, was dependent with most activities of daily living, had 1 jeopardy to resident health or venous/arterial ulcer, and was on a mechanically altered diet. safety

A 10/5/2023 Registered Dietitian #14 progress note documented the resident's estimated fluid requirements Residents Affected - Some were 1480-1725 cubic centimeters per day.

The 11/16/2023 Comprehensive Care Plan documented the resident had an actual/potential fluid deficit related to dehydration, was at risk of aspiration (inhaling food or fluid into the lungs) and had actual skin impairment related to an arterial wound on the left foot. Interventions included ensure resident had access to nectar/mildly thickened juice/water whenever possible; keep in an upright position while eating; blood urea nitrogen and creatinine laboratory tests per physician orders (potential indicators of dehydration); and monitor, document, and report to nurse signs/symptoms of fluid deficit including decreased or no urine output, concentrated urine, new onset confusion, increased pulse, and dizziness.

The 1/18/2024 physician orders documented a complete blood count (blood test that measures the number and characteristics of blood cells) and a comprehensive metabolic panel (blood test that measures chemical balance and metabolism) every month.

The 1/29/2024 Nutritional Assessment completed by Registered Dietitian #14 documented the resident was

on a pureed consistency with nectar thick liquid and was dependent with eating. Their overall fluid intake was 1501-1800 cubic centimeters a day (did not document the period for the average fluid intake). The resident did not refuse fluids.

The 2/2024 Certified Nurse Aide Survey Report documented the resident consumed 0-300 cubic centimeters of fluid daily between from 2/10/2024-2/17/2024.

There was no documented evidence the resident's poor fluid intake was reported to the medical provider.

The facility lab results report documented a lab specimen was collected on 2/15/2024 at 10:15 AM for a compete blood count and a comprehensive metabolic panel. The lab reported results to the facility on [DATE REDACTED] at 2:00 PM . The lab results were flagged with a yellow triangle to indicate there were abnormal results. The results for the complete blood count and comprehensive metabolic panel laboratory report included the following abnormal laboratory values (in orange text):

- high white blood cell count (potential indicator of infection) 13.3 units per microliter (normal 4.1-11.0 per microliter);

- low lymphocyte % (potential indicator of infection) 5.8% (normal 16-52%);

- high neutrophils % (potential indicator of infection) 86% (normal 35-75%);

- high sodium (electrolyte, potential indicator of dehydration) 149 millimoles per liter (normal 136-145 millimoles per liter);

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 - high blood urea nitrogen (potential indicator of dehydration) 35 milligrams/deciliter (normal 9-23 milligrams/deciliter); Level of Harm - Immediate jeopardy to resident health or - high blood urea nitrogen/creatinine ratio (potential indicator of dehydration) 53.8 (normal 10-20). safety

The bottom of the report had a space to sign and date when the results were reviewed. There was no Residents Affected - Some documentation the results were reviewed on the day they were received.

From 2/15/2024 to 2/17/2024, there were no documented nursing or provider notes in the resident's record regarding changes in the resident's condition.

The 2/18/2024 at 1:37 PM Registered Nurse #18 progress note documented they were notified by the licensed practical nurse the resident had abnormal vital signs. The resident was assessed and found with signs of lethargy and symptoms of change in condition including a high heart rate of 152 beats per minute (normal 60-100 beats per minute) and oxygen saturation (level of oxygen in the blood) of 70% (normal level 95-100%) on room air. Oxygen was immediately administered at 5 liters per minutes with oxygen saturation increasing to 95%. The on-call provider was notified and agreed to transfer the resident to the hospital for further evaluation. The progress note did not document if Registered Nurse #18 was aware of the 2/15/2024 laboratory results or had reported the results to the on-call provider.

The 2/18/2024 hospital report documented the resident presented from the facility for generalized weakness and was admitted with sepsis (life threatening complication of infection), acute respiratory failure, and severe hypovolemic (low fluid portion of blood) hypernatremia (high sodium). The resident's white blood cell count was high at 19 units per microliter and their sodium was high at 161 millimoles per liter. The resident was admitted to the intensive care unit and started on antibiotics and intravenous fluids, along with systemic steroids (medication to reduce inflammation) for severe pneumonia.

The 2/15/2024 laboratory results document was electronically signed by facility Nurse Practitioner #16 on 2/22/2024 at 2:49 PM, 4 days after the resident was transferred to the hospital.

During a telephone interview on 6/7/2024 at 10:24 AM, Licensed Practical Nurse Manager #13 stated every unit had a lab day and the providers followed up to review results daily. Lab values populated to all nursing and provider dashboards in the resident electronic medical record. Providers typically clicked a button indicating the labs were reviewed however nursing could do that as well. They were not sure why the resident's labs were not reviewed, and when it was reviewed, it was not done timely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page103of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 During a telephone interview on 6/10/2024 at 10:05 AM, Nurse Practitioner #16 stated if they ordered acute labs for a resident, they typically followed up the next day to review the results. If routine scheduled labs Level of Harm - Immediate were completed, they expected nursing to notify them as soon as possible of any alterations. They wanted to jeopardy to resident health or be notified of lab results such as a high white blood cell count and elevated blood urea nitrogen. They safety believed they did not work on 2/16/2024 and did not review the resident's labs until after the resident was discharged to the hospital. If they had known the resident's white blood cell count was high, they would have Residents Affected - Some intervened and ordered a chest x-ray and/or urinalysis (often used to check for urinary tract infections). For

the elevated blood urea nitrogen, they would have ordered extra hydration (fluids) by mouth or intravenously (through a vein). Earlier intervention could have resulted in a different outcome for the resident.

During a telephone interview on 6/11/2024 at 8:55 AM, Registered Dietitian #14 stated if there was a concern with lab values, the provider notified them. Laboratory values they would want to be notified about included a high blood urea nitrogen or high sodium because those could indicate dehydration. If they were made aware of the lab results, they would have done an assessment and discussed interventions with the provider. They were not aware the resident had altered lab values on 2/15/2024.

2) Resident #153 had diagnoses including Type 2 diabetes (the pancreas does not make enough insulin needed for control of blood sugar), traumatic brain injury, and dementia. The 5/17/2024 Minimum Data Set assessment (health assessment screening tool) documented the resident had moderate cognitive impairment, was usually understood, and received a hypoglycemic medication (used to reduce the amount of sugar in the blood).

The 8/15/2022 Comprehensive Care Plan documented the resident had non-insulin dependent diabetes. Interventions included monitor for signs and symptoms of hyperglycemia (high blood sugar), administer medications per physician order, monitor blood glucose finger stick, monitor for signs and symptoms of hypoglycemia including confusion, lethargy, decreased blood sugar, diaphoresis (sweating) and tachycardia (high heart rate), and monitor labs and notify physician of abnormal values.

Physician orders documented:

- on 3/2/2023 provide a controlled carbohydrate diet

- on 3/2/2023 finger stick (measure blood sugar) daily before breakfast and dinner. Call medical provider if less than 70 milligrams/deciliter or greater than 250 milligrams/deciliter.

- on 3/2/2023 glucagon emergency kit (used to treat very low blood sugar), inject 1 milligram intramuscularly as needed for severe hypoglycemia (low blood sugar) once as needed.

- on 10/19/2023 glipizide extended release (stimulates release of insulin) 5 milligrams once daily.

On 5/16/2024, Physician #41 documented the resident was seen for a routine visit. The resident had type 2 diabetes and had improved with the current medication regime.

The 6/14/2024 physician order documented comprehensive metabolic panel (blood test that measures chemical balance and metabolism) related to diabetes without complications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page104of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 The 6/2024 Medication Administration Record documented:

Level of Harm - Immediate - metformin (an oral medication used to treat high blood sugar levels) 1000 milligrams twice daily at 7:00 jeopardy to resident health or AM-10:00 AM and at 7:00 PM-9:00 PM. safety

A 6/20/2024 Licensed Practical Nurse #87 progress note documented the resident refused their 6:00 AM Residents Affected - Some finger stick. The resident refused 3 attempts.

A 6/20/2024 at 11:00 AM, Assistant Director of Nursing #25 progress note documented the resident was alert and able to verbalize their needs. They refused to take their medication and they were tired of taking all their medications. The resident verbalized an understanding of their need for medications, but still refused. The resident's family was called, and they encouraged the resident to take their medications. Their family stated

they would come to the facility to encourage the resident to take their medications and allow staff to obtain blood work.

A 6/20/2024 at 1:00 PM progress note by Registered Nurse Unit Manager #94 documented they were able to administer the resident's medications after numerous attempts.

A 6/20/2024 at 3:24 PM Assistant Director of Nursing #25 progress note documented the resident's family came to the facility and convinced the resident to allow a blood draw. The Assistant Director of Nursing drew

the blood for the ordered lab work with the family present.

The facility lab results report documented a lab specimen was collected on 6/20/2024 at 3:13 PM and received by the laboratory on 6/21/2024 at 3:04 PM. The lab results were flagged with a red stop sign to indicate a critical glucose result of 49 milligrams/deciliter (normal 70-99). The report documented the glucose result was called to and read back by Registered Nurse #89 on 6/21/2024 at 5:46 PM. The bottom of the report had a space to sign and date when the results were reviewed. There was no documentation the results were reviewed on the day they were received. The top of the lab result documented it was reviewed by Nurse Practitioner #22 on 6/25/2024 at 9:29 AM, 4 days after the results had been reported to the facility.

There was no documented evidence a medical provider was notified of the critical glucose result of 49 milligrams/deciliter, or the resident was assessed for signs and symptoms of hypoglycemia.

During a telephone interview on 6/25/2024 at 8:33 AM, the laboratory services Hematology Manager #96 stated the lab called the facility's nurse call line and asked who they were speaking to and read the results to

the nurse. The nurse read back the results, and the lab services would document the date and time of the call.

During an interview on 6/25/2024 at 9:09 AM Registered Nurse #89 stated they were a Nursing Supervisor and mainly covered the Letter building. Resident #153 had a blood draw completed on 6/20/2024 around 3:15 PM. On 6/21/2024 at 5:26 PM they received a call from the lab stating the Resident #153 had a glucose of 49. They felt the lab should have called the facility sooner. They were completing an admission assessment on another resident at the time of the call, but they called the unit to check on Resident #153.

They were told the resident had taken all their medications. They should have called a medical provider to let them know the resident had a critical result of 49 to get further orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page105of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 During an interview on 6/25/2024 at 9:11 AM, Medical Director #11 stated if a resident had an ordered blood draw the facility's lab services contacted the facility with abnormal/ critical results. They called the Nursing Level of Harm - Immediate Supervisors or Registered Nurse Unit Managers, who would then contact the medical staff to get further jeopardy to resident health or direction. If a resident had low glucose, they should be assessed by a registered nurse and the medical staff safety (physician or nurse practitioner). The lab results also were posted in the electronic medical record system so all nursing and medical staff could view them. If a resident had a glucose result of 49, they should have been Residents Affected - Some assessed by a Registered Nurse and the medical staff should have been contacted. They did not see any documentation in the resident's electronic medical record regarding a glucose of 49. They expected medical staff to be notified and if medical was not notified it could affect the resident's medical condition.

During an interview on 6/26/2024 at 1:32 PM, laboratory services Hematology Manager #96 stated the lab services protocol for the facility was to call the nursing call line and read back critical results. On 6/21/2024,

the lab services called the facility and reported a critical result glucose result of 49 for Resident #153 to Registered Nurse #89.

During a follow up interview on 7/2/2024 at 9:24 AM, laboratory services Hematology Manager #96 stated

they looked at the collection tube for Resident #153 from 6/202/204 and there was not collection time documented, but the lab did call Registered Nurse #89 on 6/21/2024 about the critical result.

3) Resident #260 had diagnoses including non-traumatic ischemic infarction (disrupted blood flow) of the right lower leg, mitral valve (a heart valve) replacement, and atrial fibrillation (irregular heart rhythm which can lead to blood clots in the heart). The 5/31/2024 Minimum Data Set assessment documented the resident was cognitively intact and received an anticoagulant (blood thinner).

The 3/10/2024 Comprehensive Care Plan documented the resident was at risk for bleeding secondary to anticoagulant use related history of deep vein thrombosis (blood clot that forms in one or more of the deep veins in the body). Interventions included to administer medications as prescribed, monitor effectiveness of medications given and observe for adverse reactions, handle resident gently during care and support the extremities under joints during movement, monitor for signs and symptoms of abnormal bleeding (skin bruising, bleeding gums, black stools, coffee ground like emesis, blood in urine), monitor lab values as ordered and notify medical of abnormal findings (PT, INR), and refer to dietary for diet modifications as needed.

Physician orders documented:

- on 5/28/2024 PT/INR (prothrombin time/international normalized ratio, used to measure how long it takes blood to clot) every Monday and Thursday and INR goal of 2.5-3.5.

- on 6/4/2024 warfarin sodium (Coumadin, an anticoagulant) 1 milligram at bedtime for valve (regular orders for warfarin sodium were documented based on INR results).

- on 6/14/2024 PT/INR one time only to monitor INR related to non-traumatic ischemic infarction of muscle of right lower leg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page106of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 The facility lab results report documented a lab specimen was collected on 6/13/2024 at 8:07 AM and received by the laboratory on 6/13/2024 at 11:59 AM. The lab results were flagged with a red stop sign to Level of Harm - Immediate indicate critical results of an INR of 5.77. The report documented the INR result was called to the facility and jeopardy to resident health or read back by (only first name documented with no title) on 6/13/2024 at 12:29 PM. The top of the lab result safety documented it was reviewed by Nurse Practitioner #22 on 6/13/2024 at 3:36 PM.

Residents Affected - Some A 6/13/2024 at 5:09 PM progress note by Registered Nurse #15 documented labs were reviewed by the nurse practitioner. Warfarin was held and labs would be repeated in the morning. There were no documented physician orders to hold warfarin on 6/13/2024.

The facility lab results report documented a lab specimen was collected on 6/14/2024 at 9:12 AM and received on 6/14/2024 at 11:46 AM. The lab results were flagged with a red stop sign to indicate critical results and included an INR of 5.05. The report documented the INR result was called to the facility and read back by Assistant Director of Nursing #25 on 6/14/2024 at 1:03 PM. The bottom of the report had a space to sign and date when the results were reviewed. There was no documentation the results were reviewed on

the day they were received. The top of the lab result documented it was reviewed by Nurse Practitioner #22

on 6/15/2024 at 10:29 AM.

The 6/14/2024 at 10:06 PM Registered Nurse #15 progress note documented the INR was reviewed with the nurse practitioner. The warfarin would be held as ordered and repeat labs as ordered. There were no documented physician orders to hold warfarin on 6/14/2024.

There were no documented medical provider progress notes referencing the critical INR values on 6/13/2024 and 6/14/2024.

The 6/2024 Medication Administration Record documented the resident did not receive warfarin on 6/13/2024 and 6/14/2024.

During an interview on 6/25/2024 at 9:11 AM, the Medical Director stated the facility was notified by the laboratory of critical lab results. The laboratory would usually report the labs to the Nursing Supervisor or the Unit Managers. The nurses would then call the provider to report the results and receive direction on how to proceed. The provider should be notified of critical lab results immediately so they could be urgently addressed. If an INR was out of range, it could be considered a critical lab value. If INRs were reported to the facility between 5:00 PM-7:00 AM the telehealth provider should be notified. Resident #260's INRs were addressed by Nurse Practitioner #22 after the registered nurse notified them, and the warfarin was held on 6/13/2024 and 6/14/2024. If an INR falls outside the range of 2.5-3.5 for a mechanical heart valve, the provider needed to be notified to determine if further action was needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page107of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 During an interview with Nurse Practitioner #22 on 6/25/2024 at 9:13 AM, they stated if there were any critical laboratory values the facility's contracted laboratory called the nursing supervisor and informed them Level of Harm - Immediate of the critical values. The nursing supervisor would then call them during the day if critical values were called jeopardy to resident health or in during the off shifts and the on-call medical provider would be notified. They checked the Dashboard safety (feature in the electronic medical record that alerted staff to outstanding/ critical laboratory values) twice daily each unit. If they noticed any outstanding/ critical laboratory values, they reviewed the resident's record and Residents Affected - Some saw the resident. Resident #260 had an artificial heart valve. If an INR falls outside the range of 2.5-3.5 for a mechanical heart valve, the provider needed to be notified to determine if further action was needed. Resident #260's INR was 5.35 and they ordered their scheduled warfarin to be held 6/24/2024 at 3:22 PM and ordered another INR to be completed on 6/25/2024. The resident received their warfarin in the evening, so they documented their note later in the day. If they held the resident's warfarin too much, they would get subtherapeutic (a dose that is below what is used for treating disease or producing an optimal therapeutic effect) levels. They would consider prescribing vitamin K if the resident's INR was 5 -6 and if the resident was bleeding. They thought the nursing supervisor documented when the laboratory called the facility with critical values, but they did not see any documentation at this time.

10 NYCRR 415.20

_____________________________________________________________________________________

Immediate Jeopardy was identified, and the Administrator was notified on 6/27/2024 at 7:00 PM. Immediate Jeopardy was removed on 7/3/2024 at 11:43 AM prior to survey exit based on the following corrective actions taken.

As of 7/3/2024 at 9:00 AM, 86% of all licensed nursing staff have been educated on laboratory services.

The remaining staff will be educated prior to the start of their next shift.

Post-tests were reviewed.

Staff education sign in sheets were reviewed and compared to the current nursing staff list and no discrepancies were identified.

100% of licensed nursing staff currently working on 7/3/2024 received education.

Staff education was verified during an onsite visit(s) 7/3/2024, multiple licensed nursing staff on multiple units were interviewed to determine retention of education provided and were able to accurately report content of

the education.

35045

44838

48895

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page108of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 27522 potential for actual harm 33421 Residents Affected - Many 35045

43754

44838

48446

48895

Based on observation and interview during the extended recertification and abbreviated (NY00336795) surveys conducted 6/4/2024-7/11/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 3 of 3 meals reviewed (6/5/2024 lunch meal on the 2nd floor, and 6/6/2024 lunch meals on the 3rd floor and on the C Unit). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during

the lunch meals on 6/5/2024 and 6/6/2024; 9 of 9 anonymous residents at the Resident Council meeting complained the food was not appetizing; and 9 residents (Residents #11, #36, #64, #105, #147, #151, #197, #255, and #265) interviewed stated the food did not taste good.

Findings include:

The facility policy, Meal Service, dated 1/2023, documented meals would be served promptly to maintain adequate temperature and appearance.

The facility policy, Food Temperatures, dated 1/2023, documented that all employees were responsible to notify the supervisor of any food item that did not meet the regulated safe acceptable service ranges (at or below 41 degrees Fahrenheit or above 135 degrees Fahrenheit).

During an interview on 6/4/2024 at 10:54 AM, Resident #151 stated that hot food was not always served hot, and the food did not taste good.

During an interview on 6/4/2024 at 11:36 AM, Resident #36 stated the food was not good. The items served were too tough to eat or were cold.

During a resident group interview on 6/4/2024 at 2:25 PM, 9 anonymous residents stated the food did not taste good.

During a lunch meal observation on 6/5/2024 at 12:44 PM on the 2nd floor, Resident #195 was served their lunch meal tray. A replacement tray was ordered, and Resident #195's original meal tray was tested . At 12:47 PM food temperatures were taken. The corn was measured at 115 degrees Fahrenheit, the coleslaw was 57 degrees Fahrenheit, the yogurt was 62 degrees Fahrenheit, and the apple sauce was 56 degrees Fahrenheit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page109of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During a lunch meal observation on 6/6/2024 at 12:21 PM, the meal cart arrived on the 3rd floor at 12:24 PM. Resident #189's meal tray was the last on the cart and was tested . A replacement tray was ordered for Level of Harm - Minimal harm or Resident #189. At 12:30 PM food temperatures were taken. The yogurt was measured at 65 degrees potential for actual harm Fahrenheit, the fortified pudding was 67 degrees Fahrenheit, the chocolate milk was 58 degrees Fahrenheit, and the fruit salad was 54 degrees Fahrenheit. Residents Affected - Many

During a lunch meal observation on 6/6/2024 at 2:19 PM, the meal cart arrived on the C Unit at 2:17 PM. Resident #105's meal tray was tested , and a replacement tray was ordered. At 2:19 PM temperatures were taken. The cottage cheese and fruit platter was measured at 67 degrees Fahrenheit, the chocolate milk was 63 degrees Fahrenheit, and the pudding was 71 degrees Fahrenheit. The cottage cheese and fruit platter was not appealing in appearance due to an abundance of liquid on the plate.

During an interview on 6/7/2024 at 10:50 AM, the Food Service Director stated hot food temperatures were checked by the cooks in the kitchen before the food went on the tray serving line. Temperatures were then checked every hour while the food was on the tray serving line. Cold food temperatures were not checked unless there was an issue with the refrigeration.

During an interview on 6/10/2024 at 10:31 AM, Licensed Practical Nurse Unit Manager #2 stated residents complained about the temperatures of the food, the amount of food received, the food did not look appetizing, and the food did not taste good. The temperatures of the food were mostly related to the cold foods which were warm. The kitchen put cold food on the tray with the hot food and closed the doors on the food cart which warmed up the cold foods.

During a follow up interview on 6/12/2024 at 10:23 AM, the Food Service Director stated they expected hot food temperatures to be above 125 degrees Fahrenheit. Cottage cheese, pudding, and chocolate milk were supposed to be served cold. The cold food was expected to be below 40 degrees Fahrenheit. Temperatures of 63, 67, and 71 degrees Fahrenheit were not acceptable for chocolate milk, cottage cheese, and pudding, respectively.

10NYCRR 415.14(d)(1)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page110of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43754

Residents Affected - Many Based on observation, interview, and record review during the extended recertification survey conducted 6/4/2024-7/11/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service in the facility's main kitchen. Specifically, food was not stored at safe temperatures in the main kitchen front walk-in cooler, and the cook's prep box walk-in cooler; there were uncleanable surfaces on the tray line floor and the storage room walls and ceiling; and the pull box walk-in cooler door was in disrepair.

Findings included:

The facility policy, Food Storage, dated 7/19/2023, documented sufficient storage facilities were provided to keep foods safe, wholesome, and appetizing. Food was stored in an area that was clean, dry, and free from contaminants. Food was stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Temperature control for safety of foods must be maintained at or below 41 degrees Fahrenheit. Periodically take temperatures of refrigerated foods to assure temperatures were maintained at or below 41 degrees Fahrenheit. Temperatures for refrigerators should be between 35 and 40 degrees Fahrenheit. Thermometers should be checked at least two times each day and checked for proper functioning of the unit at the same time.

Improper cold holding:

During an observation and interview on 6/4/2024 at 9:59 AM, a large pan (approximately 2-foot by 3-foot by 6-inches deep) of turkey salad was in the cook's prep box walk-in cooler and the temperature measured 47-49 degrees Fahrenheit. The Food Service Director stated they thought the turkey salad may have warmed up because staff had been in and out of that walk-in cooler when they started prep that morning. Other items located around the turkey salad were also measured: a pan of sausage was measured at 40.5 degrees Fahrenheit; and ground chicken was measured at 40 degrees Fahrenheit. [NAME] #78 stated those items were made last night by [NAME] #77 and were going to be served for dinner as the main menu option

on 6/4/2024.

During an interview on 6/4/2024 at 10:10 AM, the Food Service Director stated the turkey salad contained ground deli turkey and mayonnaise and should be maintained below 41 degrees Fahrenheit. They stated potentially hazardous food was only allowed to be out of temperature for 30 minutes during preparation to prevent the growth of bacteria. They stated [NAME] #77 would have left the facility last night around 7:00 PM, so the turkey salad had been in the cooler for the past 15 hours. But it must have been left out too long

during preparation and the temperature was not properly maintained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page111of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an interview on 6/7/2024 at 11:15 AM, [NAME] #77 stated they prepared the turkey salad that was identified out of temperature on 6/4/2024. They stated they used cold deli turkey and four gallons of Level of Harm - Minimal harm or prechilled mayonnaise to prepare the turkey salad. They thought it took them about 30 minutes to prepare potential for actual harm the turkey salad. It was then placed in the cook's prep box walk-in cooler. [NAME] #77 stated the salad should be maintained at 40 degrees Fahrenheit or below and was only allowed out of temperature for one Residents Affected - Many hour during preparation. They stated they documented at the end of their preparation that the turkey salad was measured at 41 degrees Fahrenheit as it was placed in the walk-in cooler.

There was no documented evidence of the recorded temperature for the turkey salad.

During an interview on 6/12/2024 at 10:23 AM, the Food Service Director stated they could not locate the documentation of the preparation temperature. [NAME] #77 told them they were sure they put that on a paper that was located on top of the pan of turkey salad when they put it away in the cooler on 6/3/2024 .

They stated someone must have pulled it from the cooler that morning and discarded the paper.

Walk-in cooler:

During an observation on 6/5/2024 at 12:05 PM, the main kitchen front walk-in cooler had a hanging thermometer in the middle of the unit that read 46 degrees Fahrenheit. The cooler contained all the dairy products and drinks for the facility. The following food item temperatures were measured:

- margarine 46 degrees Fahrenheit

- a half gallon of skim milk from the middle of a crate in the corner of the cooler 48 degrees Fahrenheit

- a half gallon of 2% milk from the middle of the bottom crate 47 degrees Fahrenheit.

- a half-gallon of milk 49 degrees Fahrenheit.

- a cup of egg salad 48 degrees Fahrenheit.

Staff attempted to keep the cooler closed but continued to enter and exit during lunch service. At 12:52 PM,

the same milks were measured at 49 degrees Fahrenheit, and the egg salad was 48 degrees Fahrenheit.

The Assistant Food Service Director pointed out that the back of the condenser in the cooler was encased in ice and may have been preventing the unit from working properly.

During a continuous observation on 6/5/2024 from 1:05 PM to 2:00 PM, the front walk-in cooler remained closed to see if it would regain proper temperature.

During an observation on 6/5/2024 between 2:00 and 2:20 PM, the following items in the front cooler were measured between 46-49 degrees Fahrenheit and voluntarily discarded:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page112of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 9 crates skim milk, 8 crates whole milk, 9 crates 2% milk, chocolate milk cartons - 9 crates, orange juice 10 cases, apple juice 22 cases, cranberry juice 25 cases (individual portioned cups labeled store under Level of Harm - Minimal harm or refrigeration),15 individual cartons of fortified milkshakes, lactose free milk - 9 cases, mozzarella cheese - 2 potential for actual harm cases, cottage cheese 4.5 cases, sour cream 2 cases, liquid egg cartons - 5 cases, shell eggs -1 case, and sour cream half gallons -1 case. Residents Affected - Many

The front walk-in cooler's posted temperature log documented the cooler's temperature was checked and recorded as 40 by Dietary Aide #79 on 6/4/2024 at 8:00 PM and on 6/5/2024 at 6:00 AM as 40 by Dietary Supervisor #82.

During an interview on 6/5/2024 at 12:13 PM, Dietary Aide #79 stated they checked the front walk-in cooler temperature that morning. That was the first thing they did when they came in in the morning. They read the hanging thermometer in the middle of the cooler and recorded the temperature on the log posted outside. Someone else would check the cooler again at the end of the night typically around 8:00 or 9:00 PM.

During an interview on 6/11/2024 at 12:29 PM, Dietary Supervisor #82 stated they often checked the temperature of the walk-in coolers in the kitchen which should be below 40 degrees Fahrenheit. They read

the temperature on the thermometer that hung in the cooler between 8:00 PM and 9:30 PM. They stated the supper tray line was usually done by 6:30 PM and the coolers remained closed between then and the time

they checked the temperatures.

During an interview on 6/12/2024 at 10:23 AM, the Food Service Director stated they needed to adjust their procedure to avoid opening and closing the walk-in cooler during service if it was only able to maintain temperature after it remained closed for two hours. They stated checking the cooler hours before service and hours after service was not a good measure of the coolers ability to maintain proper temperature and they should measure the products inside throughout the day to ensure they were more accurately monitoring temperatures for the safety of the residents.

Uncleanable surfaces and equipment in disrepair:

During an observation on 6/4/2024 at 9:50 AM, the kitchen floor by the tray line that extended into the cook's prep box walk-in cooler was uncleanable, rough concrete.

During observations on 6/4/2024 at 10:16 AM, and 6/5/2024 at 12:29 PM, the pull box walk-in cooler door did not close properly. It stopped short and caught the frame and remained ajar about an inch.

During an observation on 6/5/2024 at 12:23 PM, the kitchen pantry wall was in disrepair just inside the door,

the mop board had fallen off the wall, and there were stained, sagging ceiling tiles.

During an interview on 6/5/2023 at 12:23 PM, the Food Service Director stated they had not noticed the wall and ceiling in disrepair in the pantry. They stated the floor in the kitchen had been that way for a long time and they did their best to keep that area clean, but it was not smooth and easily cleanable. They were aware that the pull box walk-in cooler door tended to stick as it closed, and they were constantly pushing it closed when they passed it. They did not think they had put in any work orders for any of those items until they were identified during survey.

10NYCRR 415.14(h)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page113of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35045 potential for actual harm Based on observations, record review, and interviews during the extended recertification conducted Residents Affected - Many 6/4/2024-7/11/2024, the facility did not ensure it was administered in a manner that enabled it to use it resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body is responsible and accountable for the Quality Assurance and Performance Improvement program. Specifically, the administration failed to ensure policies and procedures were properly identified, communicated, and consistently implemented, and the administration was not aware of the extent of the deficient practices cited. Additionally, the administration did not ensure the facility had developed, implemented, and maintained an effective training program for all staff as necessary based on the facility assessment and the facility did not maintain documented record of the staff completed required trainings.

Findings include:

The 2024 facility Quality Assurance and Performance Improvement Plan documented the vision of the facility was to create an environment where the residents were valued, respected, and provided the optimal care required to meet their individual needs. The program was designed to monitor and evaluate objectively and systematically the following:

- The quality and appropriateness of all aspects of the facility performance and services.

- Identification of opportunities for improvement.

- Compliance with standards and regulations; current Standards of practice.

- Actions taken to enhance and improve quality by the facility.

- Resolution of identified problems.

- Sustainability of performance improvement interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page114of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 The undated job description for Administrator of Record documented the primary purpose of the position was to direct the day-to-day functions of the facility in accordance with current Federal, State, and Local Level of Harm - Minimal harm or standards, guidelines, and regulation that governed skilled nursing facilities and nursing homes to assure the potential for actual harm highest degree of quality of care was being always provided to the residents at the facility. The Administrator was responsible to direct all the facility employees in their specific roles and to ensure that each department Residents Affected - Many was functioning efficiently and in accordance with all corporate policies and procedures. Essential functions included: ensure the proper function of the nursing department and the clinical staff, ensure that all residents right to fair and equitable treatment, self-determination, individuality, privacy, confidentiality of information, property and civil rights including the right to lodge a complaint, were strictly enforced.

The 5/3/2024 facility assessment documented the services provided by the facility were skilled nursing, subacute services, physical therapy, occupational therapy, and speech therapy. The typical daily census range was 280-305 residents. The list of current resident diagnoses included: psychiatric/mood disorders with common diagnoses of psychosis (hallucination and delusions), mental disorders, depression, bipolar disorder (mania/depression) schizophrenia, post-traumatic stress disorder, anxiety disorder, behaviors that needed interventions, and multiple personality disorders.

Resident Self Administration of Medication Refer to citation text under

F-F697.

Residents #28, #37, #64 had unresolved pain that affected their daily functional abilities, psychosocial well-being, and diminished quality of life. This placed all residents with pain, who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care.

Provision of Medically Related Social Services Refer to citation text under

F-F745.

Residents #41, #126, #153, #235, and #250 were not provided medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

This placed all residents with mental health disorders at risk for physical, mental, and psychosocial harm that was Immediate Jeopardy and Substandard Quality of Care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page118of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0841 Lab Services/Physician Order/Notification of Laboratory Results Refer to the citation text under

F-F773.

Level of Harm - Actual harm Residents #153, #260, and #529 had critical laboratory results that fell outside of the clinical reference range and the ordering physician was not promptly notified of the results. Residents Affected - Some

This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety.

During an interview on 7/9/2024 at 1:23 PM, Nurse Practitioner #22 stated they worked with the Medical Director for [AGE] years. The corporate administration did not include the providers in their administrative discussions. 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 providers used to be an integral part of the residents care and now they were not as involved. They had medical staff meetings with administrative staff, pharmacy, and all providers. The Medical Director oversaw

the residents on 3 North. The policies were all corporate policies.

During a telephone interview on 7/10/2024 at 2:25 PM, the Medical Director stated their responsibility was overseeing of physician services, ensuring the physicians were doing their mandated resident visits, and working closely with the Administration. They were not responsible for overseeing care of every resident in

the facility, they were an attending physician with their own case load of residents. They currently did not have any input regarding facility policies. They used to have to sign off on the policies and procedures and was advised of and made aware of policy and procedure changes. They thought the facility was pulling most of the polices from the corporate level. They had gone to the Director of Nursing when they had concerns about policies and procedures and felt they were not being heard. 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. They stated they had not heard about the facility assessment and had no input into that document. In the past they would review residents and decide if the facility was able to accommodate and appropriately care for the new resident. The policies and procedures were corporate driven policies and they provided insight as requested but the corporation had their own way of doing things.

During an interview on 7/11/2024 at 8:52 AM, the Administrator stated the Medical Director participated in

the quality assurance meetings, the plan of correction, and rehospitalization s meeting. The policies come from the corporate team and the Medical Director should be aware of all the policies.

10 CRR NY 415.15(a)(1)(2)(3)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page119of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or 35045 potential for actual harm 48895 Residents Affected - Many Based on record review and interview during the extended recertification survey conducted 6/4/2024 - 7/11/2024, the facility did not ensure an effective training program for all new and existing staff was developed, implemented, and maintain based on the facility assessment to include maintaining record of the training program for 33 of 36 staff files reviewed. Specifically,the facility did not ensure staff had general orientation and required training in accordance with their facility assessment.

Findings included:

The Facility Assessment Portfolio, revised 5/3/2024, documented the primary objectives of the facility staff training was to provide employees with an in-depth review of the operation policies and procedures that would assist in providing high quality care; provide a yearly calendar of educational experiences that cover pertinent and mandatory topics for the support and care needed; and overview and provision of employee job specific competency program in which the employee must demonstrate/meet the specific job competency. Annual mandatory education for all staff included: Abuse/Neglect/Mistreatment Reporting, Fire Safety, Accident/Incidents, Code of Conduct, Media Policy, Resident Rights, HIPPA Trainings, Corporate Compliance, Psychosocial needs of the Elderly, Dementia/Alzheimer's Care, Emergency Preparation Program, Elopement, Infection control, Immunizations, Standard Precautions, Handwashing, Cultural Diversity, and Safe Patient Handling. All staff had required competencies for person centered care, behavior management, and resident rights. Additionally, certified nurse aides had required competencies that included oral care, activities of daily living care, and skin integrity monitoring. Social Service staff had required competencies for psychosocial assessment, and [Preadmission Screening and Resident Review], Level 2 Screening.

Communication:

A facility must include effective communications as mandatory training for direct care staff. There was no documented evidence of education for communication with non-verbal residents or English as a second language residents for the following staff members: Licensed Practical Nurse #2, Maintenance Technician #21, Assistant Director of Nursing #25, Licensed Practical Nurse #28, Licensed Practical Nurse #30, Licensed Practical Nurse #53, Licensed Practical Nurse #88, Registered Nurse Supervisor #89, Registered Nurse Unit Manager #94, Social Worker #107, Patient Service Liaison #108, Patient Service Liaison #109, Security Guard #110, Security Guard #111, Head [NAME] #78, Licensed Practical Nurse #98, Dietary Staff #112, Physical Therapy Assistant #113, Occupational Therapist #114, Speech Language Pathologist #115, Certified Occupational Therapy Assistant #116, Physical Therapist #117, Director of Activities #118, Housekeeper #120, Business Office Manager #121, Receptionist/Secretary #123, Central Service Assistant #124, Certified Nurse Aide #127, Certified Nurse Aide #129, Housekeeper #131,

Resident Rights:

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 A facility must ensure that staff members are educated on the rights of the resident and the responsibilities of

a facility to properly care for its residents. There was no documented evidence of annual education for Level of Harm - Minimal harm or resident rights based on the facility assessment for the following staff members: Assistant Director of Nursing potential for actual harm #25, Licensed Practical Nurse #53, Head [NAME] #78, Licensed Practical Nurse #88, Security Guard #110, Dietary Staff #112, Physical Therapy Assistant #113, Occupational Therapist #114, Certified Occupational Residents Affected - Many Therapy Assistant #116, Physical Therapist #117, Business Office Manager #121, Receptionist/Secretary #123, Central Service Assistant #124, Certified Nurse Aide #127, Housekeeper #131

Abuse/Neglect/Mistreatment:

In addition to the freedom from abuse, neglect, and exploitation requirements facilities must also provide training to their staff that at a minimum educates staff on: Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; dementia management and resident abuse prevention. There was no documented evidence of annual education for abuse, neglect, or mistreatment for

the following staff members: Assistant Director of Nursing #25, Licensed Practical Nurse #53, Head [NAME] #78, Licensed Practical Nurse #88, Security Guard #110, Dietary Staff #112, Physical Therapy Assistant #113, Occupational Therapist #114, Certified Occupational Therapy Assistant #116, Physical Therapist #117, Business Office Manager #121, Receptionist/Secretary #123, Central Service Assistant #124, Housekeeper #131. Additionally, Certified Nurse Aide #127 did not have documented competency of abuse education, and there was no evidence that re-education provided.

Quality Assurance:

A facility must include as part of its Quality Assurance and Performance Improvement program, mandatory training that outlines and informs staff of the elements and goals of the facility's Quality Assurance and Performance Improvement program. There was no documented evidence of education for quality assurance and performance improvement for the follow staff members: Licensed Practical Nurse #2, Assistant Director of Nursing #25, Licensed Practical Nurse #30, Licensed Practical Nurse #53, Head [NAME] #78, Licensed Practical Nurse #88, Registered Nurse Unit Manager #94, Security Guard #110, Dietary Staff #112, Physical Therapy Assistant #113, Occupational Therapist #114, Certified Occupational Therapy Assistant #116, Physical Therapist #117, Director of Activities #118, Housekeeper #120, Business Office Manager #121, Receptionist/Secretary #123, Central Service Assistant #124, Certified Nurse Aide #127, Certified Nurse Aide #128, Housekeeper #131

Infection Control:

A facility must include as part of its infection prevention and control program mandatory training that includes

the written standards, policies, and procedures for the program. There was no documented evidence of annual education for infection control based on the facility assessment for the follow staff members: Assistant Director of Nursing #25, Licensed Practical Nurse #53, Licensed Practical Nurse #88, Patient Service Liaison #108, Security Guard #110, Dietary Staff #112, Physical Therapy Assistant #113, Occupational Therapist #114, Certified Occupational Therapy Assistant #116, Physical Therapist #117, Business Office Manager #121, Receptionist/Secretary #123, Central Service Assistant #124, Housekeeper #131

Compliance and Ethics:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page121of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 The operating organization for each facility must include as part of its compliance and ethics program an effective way to communicate the program's standards, policies, and procedures through a training program Level of Harm - Minimal harm or or in another practical manner which explains the requirements under the program and annual training if the potential for actual harm operating organization operates five or more facilities. There was no documented evidence of annual education for compliance and ethics for the following staff members: Assistant Director of Nursing #25, Residents Affected - Many Licensed Practical Nurse #53, Head [NAME] #78, Licensed Practical Nurse #88, Security Guard #110, Dietary Staff #112, Occupational Therapist #114, Director of Activities #118, Housekeeper #120, Business Office Manager #121, Receptionist/Secretary #123, Central Service Assistant #124, Certified Nurse Aide #127, Housekeeper #131

Mental/Behavior Health:

A facility must provide behavioral health training consistent with the requirements and as determined by the facility assessment. There was no documented evidence of annual education for mental/behavioral based on

the facility assessment for the following staff members: Licensed Practical Nurse #2, Maintenance Technician #21, Assistant Director of Nursing #25, Licensed Practical Nurse #28, Licensed Practical Nurse #53, Head [NAME] #78, Licensed Practical Nurse #88, Registered Nurse Supervisor #89, Registered Nurse Unit Manager #94, Social Worker #107, Patient Service Liaison #108, Patient Service Liaison #109, Security Guard #110, Dietary Staff #112, Physical Therapy Assistant #113, Occupational Therapist #114, Certified Occupational Therapy Assistant #116, Physical Therapist #117, Director of Activities #118, Housekeeper #120, Business Office Manager #121, Receptionist/Secretary #123, Central Service Assistant #124, Certified Nurse Aide #125, Certified Nurse Aide #128, Certified Nurse Aide #127, Certified Nurse Aide #129, Housekeeper #131

During an interview on 7/2/2024 at 8:34 AM, Assistant Director of Nursing #25 stated annual competencies were completed in packets and done yearly. They completed their packets in February or March 2024. The packet included abuse, infection control, fire safety, and lateral violence.

During an interview on 7/8/2024 at 12:56 PM, Occupational Therapist #114 stated they received a general orientation to the facility with a policy and procedure binder. They stated they attended a townhall where they discussed education topics. They received education on the use of the language line to assist with English as a second language but could not recall specific education for non-verbal residents.

During an interview on 7/8/2024 at 1:00 PM, Certified Nurse Aide #90 stated they attended general orientation for approximately 4 hours and could not remember specific orientation for their job. They did not remember getting education on communication with English as a second language residents or non-verbal residents but had knowledge from education at other facilities. They stated that they facility did not have any quality improvement projects currently and did not know anything about the quality meetings. They were not sure if they had received mental/behavior health care training, they recalled watching something on a screen and signing for it.

During an interview on 7/8/2024 at 1:00 PM, Registered Nurse Unit Manager #94 stated they had received general and specific job orientation. They knew what Quality Assurance and Performance Improvement was

before they were hired but did not get training on it. The facility told them the quality indicators but was not sure what the quality improvement goals were currently. They stated they had to do their own education for some of the behavior residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page122of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 During an interview on 7/8/2024 at 1:10 PM, Physical Therapy Assistant #113 stated they were provided a read and sign style education for general orientation when they started 4 years ago. The specific orientation Level of Harm - Minimal harm or for their job was an additional read and sign education. They attended townhall meetings once a month with potential for actual harm read and sign topics. The rehabilitation department had ongoing classroom education.

Residents Affected - Many During an interview on 7/8/2024 at 1:14 PM, Patient Service Liaison #108 stated they attended an 8-hour general orientation and did not receive a job specific orientation. They did not receive education on how to communicate with English as a second language residents or non-verbal residents. They knew there were quality improvement topics, but could not recall any, and did not know how to bring a topic to the Quality Assurance and Performance Improvement committee. They stated they did not receive education about mental health. They learned about dementia care in orientation on day 1, and about 3 months ago.

During an interview on 7/8/2024 at 1:18 PM, Social Worker #107 stated they received education on how to use the language line from their first line supervisor for residents with English as a second language, but not

a formal training.

During an interview on 7/8/2024 at 1:23 PM, Licensed Practical Nurse #28 stated they did not receive weekly education or training. They did not received education on English as a second language at the facility but knew of it from experience elsewhere. They were not aware of Quality Assurance or Performance Improvement goals, and if they had suggestions for quality improvement, they would discuss it with their Unit Manager. 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.

During an interview on 7/8/2024 at 1:36, the Business Office Manager #121 stated when they were hired on 5/20/2019, they received a general orientation that consisted of two days. They did not receive ongoing training or competencies except at a corporate level for new programs. They did go over residents' rights on

a yearly basis along with the corporate trainings. The facility had a language line for residents whose primary language was not English. They recently received education on transmission-based precaution in relation to enhanced barrier precautions. They had received infection control training in the last few weeks. They did not receive training for mental and behavioral health care needs or dementia care training.

During an interview on 7/8/2024 at 1:42 PM, Patient Service Liaison #109 stated they started working in the facility on a Monday and attended the general orientation day on Thursday. They stated they did not receive ongoing training; training on communication with English as a second language residents, or non-verbal residents; training on current goals of Quality Assurance and Performance Improvement; or training for resident specific mental and behavioral health care needs. They stated they never received education on mental/behavioral health care needs or dementia care.

During an interview on 7/8/2024 at 2:01 PM, Licensed Practical Nurse #2 stated they had less than an hour of education a month. They did not recall receiving education for communicating with non-verbal residents.

They learned about the language line for residents that were not native English speakers on their day 1 orientation in 2022. They stated they had Quality Assurance and Performance Improvement education, because they went to the Quality Assurance and Performance Improvement meeting every month. They stated they did not believe they had ever received education for mental and behavioral health needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page123of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 During an interview on 7/8/2024 at 2:03 PM, Central Service Assistant #124 stated they worked overtime hours as a certified nurse aide. They did not receive education for non-verbal or English as a second Level of Harm - Minimal harm or language residents. It was important to be able to speak with all residents, and they had suggested that type potential for actual harm of education to the previous educator.

Residents Affected - Many During an interview on 7/8/2024 at 2:13 PM, Certified Occupational Therapy Assistant #116 stated they were most recently hired in June of 2023. They stated they had a general orientation that was mostly PowerPoint presentations with opportunity to ask questions. They received orientation to their job through read and sign documents. They had weekly in-department meetings with the therapy department for ongoing training and

the facility also had facility-wide town hall meetings. They had yearly training on residents' rights. They received yearly dementia care, behavioral health, handwashing, and transmission-based precaution training.

During an interview on 7/8/2024 at 2:13 PM, Licensed Practical Nurse #30 stated they were provided general and specific orientation for their role. They stated they had been doing in-services over the phone recently.

They did not receive education on a weekly basis, just periodically. There were not provided education on communicating with non-verbal or English as a second language residents at the facility. They were not sure how to bring quality improvement suggestions to the committee.

During an interview on 7/8/2024 at 2:19 PM, the Director of Activities #118 stated they were hired in October 2022 and had a general orientation in a classroom style setting. They received specific job training through

the previous Activity Department Director and the regional for the activity department. They received education through in-services and sometimes through a zoom meeting for their department. They received quarterly residents' rights, behavioral health care needs, transmission-based precaution, and handwashing training. Infection control and dementia training was yearly.

During an interview on 7/8/2024 at 2:27 PM, Licensed Practical Nurse #98 stated they had 1 day of specific orientation for their role. They did not receive ongoing training or competencies. They received no other training other than State concerns. They did not know what the current quality improvement goals were, or how to bring concerns to the committee. They did not receive education for mental and behavioral health care needs.

During an interview on 7/8/2024 at 2:43 PM, Certified Nurse Aide #128 stated they were not sure if they received specific orientation for their job. They did not receive ongoing training or competencies. They did not have education on communicating with non-verbal or English as a second language residents. They were not aware of that quality improvement was or the current goals of the committee. They did not receive any education regarding mental and behavioral health.

During an interview on 7/8/2024 at 2:44 PM, Licensed Practical Nurse #53 stated they were hired in January of 2023 and received general orientation classroom style. They stated the first two days of their orientation was in the classroom and then they shadowed someone. They stated that people should be on orientation longer. They only received training weekly if someone did something wrong and there was re-education.

They did not receive communication training on how to communicate with residents whose primary language was not English or non-verbal residents. Some residents had the translator information in their room but there was no formal education. They received training on dementia once a month, usually when something happened. They received weekly training on transmission-based precautions and hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page124of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 During an interview on 7/8/2024 at 2:44 PM, Licensed Practical Nurse #87 stated they knew of quality improvement but did not know the current goals of the facility. They did not know if they had received Level of Harm - Minimal harm or education for resident specific mental and behavioral health care needs, they did not receive general potential for actual harm mental/behavior health education.

Residents Affected - Many During an interview on 7/8/2024 at 3:02 PM, Maintenance Technician #21 stated they were taught to find a nurse if someone did not know who they were or why they were there during orientation regarding communicating with residents that were non-verbal or English as a second language. They stated they did not know what quality improvement was, and they did not receive any training on current goals for quality improvement.

During an interview on 7/8/2024 at 3:15 PM, Registered Nurse Supervisor #89 stated they did not recall receiving education for communicating with non-verbal residents. They stated they were just educated about Quality Assurance and Performance Improvement recently when they started attending the Quality Assurance and Performance Improvement meeting. They stated outside of those meetings, they did not receive education.They thought there was education for dementia care related to mental health, but they did not stay in the classroom for the entire day 1 orientation. They went to the unit to do more supervisor and management related training instead.

The 7/8/2024 at 3:55 PM, electronic communication from the Director of Nursing documented Security Guard #110 was a vendor employee and worked to cover an absent employee, and they did not have a personnel file for them.

During an interview on 7/9/2024 at 9:31 AM, Housekeeper #120 stated they had ongoing monthly training to show them the steps to complete their job. These trainings included the 5 steps of cleaning, high dusting, low dusting, bed, trash, and cleaning floor then the bathroom. They were trained that to communicate with English as a second language and non-verbal residents to ask the supervisor if the resident could communicate. They were educated on resident specific mental and behavioral health care needs and dementia care during orientation in 2021.

During a telephone interview on 7/9/2024 at 10:00 AM, Security Guard #111 stated they attended a general orientation, but did not have a specific orientation to their job. They stated they did not receive ongoing education.

During an interview on 7/9/2024 at 10:16 AM, Head [NAME] #78 stated they had Spanish speaking residents, they could communicate in Spanish with, or they would find a nurse on the unit that better understood the resident. For quality improvement, they stated they knew that department heads got together to discuss improvement projects. They stated they did kitchen specific trainings with their staff. They did not receive dementia care traing but had knowledge from education provided at another facility. They had an update for resident specific mental and behavioral health care needs but could not recall when.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page125of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 During an interview on 7/10/2024 at 1:59 PM, Assistant Director of Nursing/Nurse Educator #27 stated they were responsible for the education for all staff. Education was done through an orientation at the beginning Level of Harm - Minimal harm or of their employment, and they started a quarterly or monthly calendar that depended on the training potential for actual harm schedule. They had set topics that were based on the plan of correction. They provided education that was required by regulation.Their annual competencies consisted of hand washing, medication administration, Residents Affected - Many dressing changes, fire safety, abuse training, and dementia. Corporate provided the education to ensure competencies and education matched what resident needs were identified on the facility assessment. They were unable to give a definitive answer to how education was tracked. They stated it was important to have competent staff in the building so that residents were taken care of properly.

During an interview with the Administrator and Director of Nursing on 7/11/2024 at 8:52 AM, the Administrator stated the focus of education was on the plan of correction. They stated they held townhall meeting once or twice a month for all 3 shifts; where they discussed the plan of correction, advise where the facility stood with the Department of Health, and discussed how to avoid repeated deficiencies. They identified areas of concern and was working on the record keeping for the facilities education. They ensured all staff received mandatory trainings by having a good orientation process. The Director of Nursing stated

the education program matched the needs of the residents identified in the facility assessment but was geared more towards the regulatory results. The facility provided dementia care education, but not anything related to other mental health management. It was important to ensure staff were trained completely prior to providing direct care to ensure competency.

The 7/11/2024 at 11:15 AM, electronic communication from the Director of Nursing documented they were unable to locate any staff files for Patient Service Liaison #108, Dietary Staff #112, Certified Occupational Therapy Assistant #116, and Authorization Specialist #121.

10 NYCRR 415.26

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page126of126 335338

F-F940.

Level of Harm - Minimal harm or The facility did not have a training program developed to ensure that all staff had received required trainings potential for actual harm based on the facility assessment. Training was not recorded as completed for all staff in the following areas: communication, resident rights, abuse and neglect, Quality Assurance Performance Improvement (QAPI), Residents Affected - Many infection control, and compliance and ethics. Based on the facility assessment the facility staff should have received training on specific behavioral health conditions and management.

During an interview with the Administrator and Director of Nursing on 7/11/2024 at 8:52 AM, the Administrator stated the focus of education was on the plan of correction with policy and procedure updates.

They stated they held townhall meetings once or twice a month for all 3 shifts; where they discussed the plan of correction, advised where the facility stood with the Department of Health, and discussed how to avoid repeated deficiencies. They identified areas of concern and was working on the record keeping for the facilities education. They ensured all staff received mandatory trainings by having a good orientation process, with each Department Head presenting what was important to their department. The administrator indicated the process for maintaining proper record of training was a work in progress and was not perfect.

The Administrator stated the role of the Administrator was to oversee the day-to-day operations of all the functioning departments. They stated they were not a nurse or a clinician, but they should know about everything going on in the building with every department. They had daily morning reports and group meetings to addresses certain areas. They met with the Director of Nursing to discuss current processes and how to improve in certain areas. It was important to have thorough communication with the interdisciplinary team members, and they stated they made rounds on the resident care units.

The Administrator stated the Medical Director participated in the quality assurance meetings, the plan of correction, and rehospitalization s meeting. The policies come from the corporate team and the Medical Director should be aware of all the policies.

During the same interview with the Administrator and the Director of Nursing on 7/11/2024 at 8:52 AM, the Director of Nursing stated the education program matched the needs of the residents identified in the facility assessment but was geared more towards the regulatory results. The facility provided dementia care education, but not anything related to other mental health management. The Director of Nursing stated the importance of having trained competent nursing staff was to ensure staff could give safe and quality care to

the residents. It was important to ensure staff were trained completely prior to providing direct care to ensure competency. The lack of competent staff negatively impacted their quality assurance.

An electronic communication from the Director of Nursing on 7/11/2024 at 11:15 AM, indicated they were unable to locate any staff files for Patient Service Liaison #108, Dietary Staff #112, Certified Occupational Therapy Assistant #116, and Authorization Specialist #121.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page116of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 During a telephone interview on 7/10/2024 at 2:25 PM, the Medical Director stated their responsibility was overseeing of physician services, ensuring the physicians were doing their mandated resident visits, and Level of Harm - Minimal harm or working closely with the Administration. They were not responsible for overseeing care of every resident in potential for actual harm the facility, they were an attending physician with their own case load of residents. They currently did not have any input regarding facility policies. They used to have to sign off on the policies and procedures and Residents Affected - Many was advised of and made aware of policy and procedure changes. They thought the facility was pulling most of the polices from the corporate level. They had gone to the Director of Nursing when they had concerns about policies and procedures and felt they were not being heard. 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. They stated they had not heard about the facility assessment and had no input into that document. In the past they would review residents and decide if the facility was able to accommodate and appropriately care for the new resident. The policies and procedures were corporate driven policies and they provided insight as requested but the corporation had their own way of doing things.

During an interview on 7/9/2024 at 1:23 PM, Nurse Practitioner #22 stated they worked with the Medical Director for [AGE] years. The corporate administration did not include the providers in their administrative discussions. 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 providers used to be an integral part of the resident's care and now they were not as involved. They had medical staff meetings with administrative staff, pharmacy, and all providers. The Medical Director oversaw

the residents on 3 North. The policies were all corporate policies.

During a telephone interview on 7/11/2024 at 8:54 AM, the Division President of the company stated their role was to ensure the facility had a Licensed Administrator. They reviewed the facility assessment and made sure there were means of communication in place. They had scheduled calls each week with the Administrator to go over operation concerns and to work on facility issues together.

10 NYCRR 483.70(i)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page117of126 335338 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335338 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0841 Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35045 Residents Affected - Some Based on record review and interviews during the extended recertification survey conducted 6/4/2024-7/11/2024 the facility's Medical Director did not ensure the coordination of medical care with interdisciplinary teams and implement and evaluate resident care policies to assure they reflected current professional standards. Specifically, the Medical Director failed to ensure that policies and procedures were developed and implemented to provide and monitor the delivery of care and services to residents in the areas of Self-administration of Medication (F 554), Pain Management (F 697), Laboratory Services/Notification of Results (F 773), and Provision of Medically Related Social Services (F 745), resulting

in actual harm with potential for serious harm that was Immediate Jeopardy.

Findings included:

The undated facility Medical Director Job Description documented the Medical Director was a physician who served as the leader in the clinical setting or a health care facility. They were responsible for developing and implementing policies and procedures and best medical practices and coordinating care in the facility. They would oversee training and provide continuing education for their staff. The Medical Director would assure

the medical facility was in line with all State, Federal and Local laws and should directly report any relevant information to the senior management of the facility. Additionally, the Medical Director would supervise the medical staff, review, and participate in quality assurance activities and directly oversee clinical safety and risk management.

Resident Self Administration of Medication Refer to citation text under