A Complete Quality and Culture Turnaround at a New York Skilled Nursing Facility.
The Challenge: CMS Special Focus Facility Status and Threat of Closure
Bishop, a skilled nursing facility in New York, faced severe regulatory, clinical, and operational challenges prior to Everest’s engagement. Prolonged instability, recurring deficiencies, and sustained inclusion on the CMS Special Focus Facility (SFF) list had placed the organization at risk of imminent closure by the New York Department of Health (NY DOH).
When Everest Management Solutions began working with Bishop in July 2024, the facility faced:
- 25 survey citations, including one at severity level K.
- A history of prolonged SFF status and ongoing regulatory oversight.
- Persistent clinical and operational system failures.
- Low staff morale resulting from years of instability and compliance pressure.
The NY DOH had issued formal warnings that closure was imminent if measurable improvement was not achieved immediately.
Our Approach: Comprehensive Regulatory Recovery and Quality Improvement
Everest implemented a comprehensive turnaround plan focused on immediate stabilization, regulatory recovery, and long-term sustainability. The plan was designed to restore confidence, rebuild systems, and create a culture of accountability and quality care.
Key actions included:
- Conducting a root cause analysis of clinical, operational, and administrative systems to identify systemic deficiencies.
- Developing a strategic remediation plan to address high-priority deficiencies and compliance gaps.
- Partnering with center leadership and interdisciplinary teams to restore and standardize clinical systems.
- Implementing daily performance reviews, structured accountability calls, and consistent executive support to ensure follow-through.
- Providing hands-on coaching and mentorship for nursing and administrative staff to strengthen leadership and compliance practices.
Through this intensive, hands-on engagement, Everest rebuilt structure, consistency, and morale, turning regulatory crisis into a roadmap for improvement.
Results: Full SFF Graduation and Regulatory Recognition
Within months, Bishop achieved measurable and sustained success across key performance areas:
- Cleared all 25 citations during the first re-visit survey.
- Reduced total citations to nine during the December 2024 annual survey, with the highest severity only level E.
- Earned recognition from CMS and NY DOH as a model for effective quality turnaround and compliance recovery.
- Received official SFF graduation notification in September 2025, marking full regulatory recovery in just 14 months.
Everest continues to provide oversight through a structured sustainability plan, including weekly progress calls, strategic performance reviews, and continuous monitoring of clinical systems to ensure enduring results.
Key Takeaway
This success story proves that even the most at-risk skilled nursing facilities can achieve complete transformation with the right partnership, strategy, and leadership alignment. Everest’s proven framework combines data-driven quality improvement with culture rebuilding to deliver measurable, lasting change.
Is your facility struggling with survey challenges or regulatory oversight? Partner with Everest Management Solutions to move from special focus to success, rebuilding compliance, culture, and confidence for long-term operational excellence.