Cycle 1
Health 2025-05-16 · Fire 2025-05-16
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Syracuse, NY
Bishop Rehabilitation And Nursing Center
1-star overall rating with 1-star inspections with $699,602 in total fines with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
918 James Street, Syracuse, NY
(315) 474-1561
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
440
Certified beds
Average residents
219
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1971-11-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
4.44
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,312
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.09
Baseline 21.65% · Performance 20.46% · Measure score 2.09 · Achievement 2.09 · Improvement 2.06
Healthcare-associated infections
4.25
Baseline 8.32% · Performance 6.74% · Measure score 4.25 · Achievement 3.65 · Improvement 4.25
Total nurse turnover
1.32
Performance 58.30% · Measure score 1.32 · Achievement 1.32 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.95
Baseline 3.52 hours · Performance 3.63 hours · Measure score 1.95 · Achievement 1.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.9% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 13.45% · Lower 95% interval 8.17% |
| Discharge to community | 26.48% |
50.57%
24.1 pts worse
|
Worse than the National Rate · Eligible stays 90 · Observed rate 14.44% · Lower 95% interval 18.19% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 66 · Denominator 66 |
| Falls with major injury | 1.52% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 66 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 16 · Denominator 40 |
| Discharge mobility score | 35% |
50.94%
15.9 pts worse
|
Numerator 14 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 2 · Denominator 66 · Adjusted rate 2.2% |
| Healthcare-associated infections requiring hospitalization | 6.74% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 7.14% · Lower 95% interval 4.52% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 256 |
| Staff flu vaccination coverage | 55.62% |
42%
13.6 pts better
|
Numerator 193 · Denominator 347 |
| Discharge function score | 40% |
56.45%
16.5 pts worse
|
Numerator 16 · Denominator 40 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20.59% |
25.2%
4.6 pts worse
|
Numerator 7 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.3 |
1.7
2.6 pts worse
|
1.9
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 4.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
1.3
2.3 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
91.2%
3.6 pts worse
|
93.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.7% · Q2 89.0% · Q3 87.1% · Q4 89.9% · 4Q avg 87.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
95.3%
3 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.0%
1 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.6% · Q3 3.8% · Q4 4.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 29.2% |
18.5%
10.7 pts worse
|
11.4%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 28.2% · Q3 27.3% · Q4 29.9% · 4Q avg 29.2% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.1%
1.1 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 5.5% · Q3 5.7% · Q4 6.8% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
13.5%
3.2 pts worse
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 15.6% · Q3 18.7% · Q4 16.9% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.9% |
14.8%
1.1 pts worse
|
16.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 17.6% · Q3 12.1% · Q4 14.1% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.0% |
15.1%
4.9 pts worse
|
16.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 20.0% · Q3 18.7% · Q4 17.4% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
15.5%
4.8 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 20.8% · Q3 21.2% · Q4 15.6% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.6%
0.3 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.4% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.4%
1.3 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 5.5% · Q3 2.9% · Q4 1.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
20.8%
8 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 30.4% · Q3 32.1% · Q4 28.0% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 8.4% |
6.9%
1.5 pts worse
|
5.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.4% · Q3 8.8% · Q4 9.7% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.9% |
76.7%
0.2 pts better
|
81.7%
4.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.3% · Q2 64.5% · Q3 84.7% · Q4 91.3% · 4Q avg 76.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
9.7%
1.1 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 11.8% · Expected 15.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
78.8%
6.9 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
20.6%
0.5 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 27.9% · Expected 33.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-20 · Fire 2024-12-20
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2024-07-11 · Fire 2024-07-11
47 health deficiencies
Top issue: Quality of Life and Care (16 deficiencies)
23 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-24
F · Potential for more than minimal harm
2025-05-16
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-05-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-05-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2025-06-24
F · Potential for more than minimal harm
2024-12-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-02-13
E · Potential for more than minimal harm
2024-12-20
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-02-13
E · Potential for more than minimal harm
2024-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-13
E · Potential for more than minimal harm
2024-12-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-13
D · Potential for more than minimal harm
2024-12-20
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-02-13
D · Potential for more than minimal harm
2024-12-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-05
D · Potential for more than minimal harm
2024-12-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-13
D · Potential for more than minimal harm
2024-12-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-13
D · Potential for more than minimal harm
2024-12-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-13
D · Potential for more than minimal harm
2024-12-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-13
D · Potential for more than minimal harm
2024-12-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-02-13
F · Potential for more than minimal harm
2024-07-11
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-11
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-11
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-07-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-25
E · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-07-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-04
C · Minimal harm
2024-07-11
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-09-04
E · Potential for more than minimal harm
2023-10-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-24
E · Potential for more than minimal harm
2024-12-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-13
E · Potential for more than minimal harm
2024-12-20
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-02-13
E · Potential for more than minimal harm
2024-12-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-13
E · Potential for more than minimal harm
2024-12-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-13
E · Potential for more than minimal harm
2024-12-20
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-12-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-13
D · Potential for more than minimal harm
2024-12-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-02-13
D · Potential for more than minimal harm
2024-12-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-13
D · Potential for more than minimal harm
2024-12-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-02-13
K · Immediate jeopardy
2024-07-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-09-04
K · Immediate jeopardy
2024-07-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-04
K · Immediate jeopardy
2024-07-11
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-09-04
K · Immediate jeopardy
2024-07-11
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-09-04
I · Actual harm
2024-07-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-04
I · Actual harm
2024-07-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-04
H · Actual harm
2024-07-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-04
H · Actual harm
2024-07-11
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-11
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-11
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-18
F · Potential for more than minimal harm
2024-07-11
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-11
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
F761 · Pharmacy Service Deficiencies
Health
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 locked, compartments for controlled drugs.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-01-19
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-02-16
H · Actual harm
2023-12-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-13
H · Actual harm
2023-12-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-28
G · Actual harm
2023-12-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-13
G · Actual harm
2023-12-05
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-05-13
D · Potential for more than minimal harm
2023-12-05
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-06-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-05-24
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-05-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-05-24
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-07-19
G · Actual harm
2023-03-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-03-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-27
Penalties and ownership
What sits behind the stars
$378,437
2024-07-11
Fine
Fine · fine $378,437
Fine
$0
2024-07-11
Payment Denial
Payment Denial · denial start 2024-08-06 · 50 days
50 day denial
$321,165
2023-12-05
Fine
Fine · fine $321,165
Fine
$0
2023-12-05
Payment Denial
Payment Denial · denial start 2024-04-16 · 42 days
42 day denial
Ownership
Farbenblum, Edward
5% Or Greater Direct Ownership Interest · Individual
Rozenberg, Eli
5% Or Greater Direct Ownership Interest · Individual
Deslauriers, Marty
Operational/Managerial Control · Individual
Kaur, Gurinder
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Central Park Rehabilitation And Nursing Center
Syracuse, NY
1-star overall rating with 1-star inspections with 11 recent health deficiencies
#2
Loretto Health And Rehabilitation Center
Syracuse, NY
2-star overall rating with 1-star inspections with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Jewish Home Of Central New York
Syracuse, NY
1-star overall rating with 1-star inspections with $121,573 in total fines with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out