Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bishop Care Center during CMS and state inspections, most recent first.
Bed placement was used as a restraint for two residents when beds were positioned directly against the wall, limiting free movement and access to exit the bed from both sides. One resident had paraplegia, cognitive communication deficit, and anoxic brain damage, while the other had altered mental status, hemiplegia/hemiparesis, and dementia. Staff and the DON confirmed the bed positions were intentional interventions for safety and fall prevention, and the DON acknowledged the restraint policy was not followed.
Insufficient nursing staffing resulted in the facility falling below the required 3.5 DHPPD on 22 of 31 sampled days, with actual direct care hours ranging from 2.42 to 3.38. The DSD, DON, and ADMIN reviewed the staffing records and acknowledged the shortage, and the CNA staffing waiver required at least 3.5 direct care service hours per patient day.
An LPN administered insulin glargine to three residents well before the ordered 6:00 AM time, with doses given about 2 hours and 21 to 29 minutes early. The residents had diabetes and other significant conditions, and the LPN confirmed the medication was a high-alert drug and that the facility med admin policy was not followed. The report also noted that another resident received chewable aspirin 81 mg instead of the ordered enteric coated aspirin 81 mg.
An infection prevention and control deficiency was cited after a resident's nebulizer had brown crusted residue and tubing left hanging without a protective bag, another resident's wheelchair was visibly soiled with dried brown crusted substance on the cushion and frame, and a third resident's oxygen tubing and nasal cannula were left on the floor while still connected to the concentrator. Staff acknowledged the equipment was not clean or stored per policy, and the DON confirmed the facility policy was not followed.
A CNA did not receive the required annual in-service training of at least 12 hours. Record review showed the CNA signed for several in-services, including fall prevention, choking prevention, abuse recognition/reporting, oral care, infection precautions, oral hygiene, emergency response procedures, and safe repositioning techniques, but the DSD stated the CNA did not meet the minimum required in-services.
A resident with acute respiratory failure with hypoxia, COPD, and osteoarthritis was observed lying in bed unable to find the call light, which was hanging off the side of the bed and out of reach. The CNA confirmed the call light was not within reach, and the DON acknowledged the facility's policy requiring call lights to remain within easy reach was not followed.
Failure to timely report an injury of unknown origin: A resident with paraplegia, cognitive communication deficit, and severe cognitive impairment was observed with bruising/discoloration around the eye. A family member and a CNA both noted the injury, but the CNA did not report it and the allegation was not reported to the State Survey Agency within the required timeframe. The DON stated staff were expected to immediately report new bruising or injuries of unknown origin.
Bathroom Emergency Call Light Not Functioning: A resident with paraplegia, cognitive impairment, and anoxic brain damage was observed waiting for staff assistance to use the restroom, but testing showed the bathroom emergency call light did not activate any alarm or notification. The DON and Administrator confirmed the call light was inoperable, and the MDR stated the equipment had been damaged repeatedly and required repairs on multiple occasions. The resident’s MDS showed severe cognitive impairment and dependent toileting hygiene.
The facility did not provide a timely written response to a grievance submitted by the Family Council, despite a policy requiring written responses within 14 days. Family Council minutes, submitted by the LTC Ombudsman to the former Administrator, documented concerns such as residents waiting two hours for incontinence pad changes and not being checked every two hours by staff. As confirmed by the DON, no written response was issued within the required timeframe, which was attributed to a change in Administrators, affecting all residents in the facility.
The facility did not provide the required minimum direct care service hours per patient day over a six-day period, resulting in insufficient nursing staff to meet resident needs. The DON confirmed ongoing staffing shortages, particularly on night shifts, due to recent CNA resignations and reliance on temporary staff. Facility records showed multiple days with DHPPD below regulatory requirements, affecting the care and safety of all residents.
The facility did not meet the required 3.5 direct care service hours per patient day on several occasions, as confirmed by staffing records and leadership interviews. On one occasion, a call light was left unanswered for 40 minutes due to lack of CNA coverage, highlighting the impact of insufficient staffing on resident care and safety.
A resident with Alzheimer's and other conditions was found with unexplained facial injuries. Staff observed and documented the injuries, and the DON and administrator were notified, but the required report to the state agency and ombudsman was delayed. The SOC341 form was submitted several days after the incident, and the facility could not provide the mandated 5-day investigation report, resulting in a deficiency for failure to follow reporting and investigation protocols.
The facility did not provide the required minimum direct care service hours per patient day on multiple occasions, as confirmed by staff interviews and record reviews. Staff shortages, discontinuation of registry and travelers, and unfilled vacancies led to insufficient staffing, preventing adequate care and supervision for residents, including those with wandering behaviors. Leadership acknowledged awareness of the issue and that facility policy and waiver requirements were not met.
The facility failed to maintain RN coverage for eight consecutive hours, seven days a week, as required by policy. On multiple occasions, no RN was scheduled, and the DON was only on-call, not physically present. Staff interviews confirmed the necessity of RN presence for certain treatments, highlighting a scheduling issue that led to this deficiency.
The facility failed to provide sufficient staffing on three sampled days, with direct care service hours per patient day falling below the required 3.5 DHPPD. This deficiency was confirmed through interviews and record reviews with the Administrator and DON, who acknowledged the staffing issues and the failure to adhere to the facility's staffing waiver. The deficiency had the potential to impact the psychosocial and physical needs of 93 residents.
The facility failed to provide adequate hydration to three residents, leading to potential health risks. Residents reported delays in receiving assistance and inconsistent water distribution. Staff interviews revealed confusion about responsibilities for hydration, and the Director of Nursing acknowledged the issue. Facility policies on hydration were not adhered to, as evidenced by empty water pitchers and resident complaints.
Three residents experienced significant delays in receiving assistance, with one resident left soiled for hours and others waiting over an hour for help after using call lights. The facility's staffing issues contributed to these deficiencies, as confirmed by staff interviews.
The facility failed to serve meals at an appetizing temperature to three residents, as required by its food and nutrition services policy. The residents reported receiving cold meals, and the DON acknowledged that staffing challenges and improper handling of meal carts might be contributing factors.
The facility failed to follow its garbage disposal policy by leaving four outdoor dumpsters open, as observed during an inspection with the Maintenance Director. The DON acknowledged the risk of attracting rodents, which could pose a health risk to the 89 residents. The facility's policy and the FDA Federal Food Code require dumpsters to be kept closed to prevent attracting pests.
The facility failed to maintain its pest control program, leading to a reported sighting of mice, affecting 89 residents. A resident reported seeing a mouse inside the facility, which was confirmed by the Maintenance Director. The DON acknowledged the presence of mice and stated that the pest control program had been discontinued due to budget reasons. The facility's policy indicated an ongoing pest control program was required.
The facility failed to follow its policy for timely call light response, affecting four residents with various medical conditions, including difficulty walking and muscle weakness. Residents reported long wait times for assistance, with one noting delays of up to 45 minutes. The DON acknowledged the issue, which contradicts the facility's policy requiring prompt response to call lights.
A resident reported inappropriate conduct by a CNA, who was hired before completing a background check, to the facility Administrator. The Administrator failed to initiate an investigation or report the incident to the relevant agencies within the required timeframe, only addressing the issue after it was brought to attention by the ombudsman a week later. This failure to follow the facility's abuse prevention and reporting policies placed the resident and others at risk.
A resident reported inappropriate touching by a CNA, but the facility failed to suspend the CNA immediately as per policy. The CNA continued to work for two days, maintaining contact with the resident and others. The Administrator admitted forgetting to place the CNA on leave, and HR was unaware of the need for removal from the schedule.
A facility failed to administer medications timely to a resident with peripheral vascular disease, missing several doses due to a breakdown in communication and procedure adherence. Additionally, three residents experienced significant delays in call light responses, particularly during nighttime hours, due to insufficient staffing. These deficiencies posed potential risks to the residents' health and safety.
A CNA failed to report suspected abuse of a resident within the required timeframe, delaying the facility's investigation. The resident, with moderate cognitive impairment, was allegedly abused by another staff member. Facility policy mandates immediate reporting of such incidents.
Bed Placement Used as a Physical Restraint
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical restraints when equipment and bed placement restricted their ability to move freely and exit the bed. For one resident, the bed was positioned against the wall on the left side with a floor mat on the opposite side, and the bed frame and mattress were observed directly adjacent to the wall with no visible space between the bed and the wall. The Director of Nursing confirmed that the bed was positioned against the wall as a nursing intervention, but no physician order was identified authorizing placement of the bed in a way that restricted exit from one side. That resident’s record showed diagnoses including paraplegia, cognitive communication deficit, and anoxic brain damage. The MDS indicated severe cognitive impairment with a BIMS score of 5, and functional assessments showed the resident required assistance with rolling and substantial to maximal assistance with sit-to-lying. The physician orders included half side rails to both sides of the bed for safety and repositioning, and a fall mat at bedside on both sides of the bed to reduce risk of injury from attempts to crawl out of bed. The facility’s restraint policy stated that practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, and the DON acknowledged the bed placement could affect the resident’s ability to exit the bed from the side. For the second resident, the bed was observed with one side flushed directly against the wall and a fall mat on the other side. Staff confirmed the bed had been positioned against the wall to reduce the likelihood of falling out of bed and to create more room for equipment, and they acknowledged that this placement restricted the resident’s freedom of movement and blocked access to one side of the bed. The resident’s diagnoses included altered mental status, recurrent major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and dementia. The DON confirmed the bed was positioned against the wall to reduce the risk of the resident exiting the bed and falling, and acknowledged the facility’s restraint policy was not followed.
Insufficient Nursing Staffing and Direct Care Hours
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to maintain the required licensed nurse coverage on each shift. During interview and record review, the facility’s Census and Direct Care Service Hours Per Patient Day (DHPPD) report for April 18, 2026, through May 18, 2026, showed that 22 of 31 sampled days were below the required 3.5 direct care service hours per patient day. The actual DHPPD ranged from 2.42 to 3.38 on the deficient dates, with shortages ranging from 0.12 to 1.08 hours per patient day. During the concurrent interview on May 20, 2026, the DSD, DON, and Administrator reviewed the staffing data and acknowledged that the facility did not meet the required DHPPD on those dates. The facility’s staffing waiver for CNAs, valid from July 1, 2025, to June 30, 2026, stated that the facility shall provide no less than 3.5 direct care service hours per patient day. The report states this failure had the potential to result in unmet psychosocial and physical needs and safety concerns for 97 residents in the facility.
Medication Administration Errors With Early Insulin Doses and Wrong Aspirin Formulation
Penalty
Summary
Safe and effective pharmaceutical services were not provided when insulin glargine was administered earlier than ordered for three residents who had diabetes mellitus. Resident 7 had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, chronic kidney disease stage 3, and vascular dementia with behavioral disturbance. Resident 35 had type 2 diabetes mellitus with diabetic neuropathy, heart failure, and difficulty walking. Resident 46 had type 2 diabetes mellitus with diabetic neuropathy, essential hypertension, and difficulty walking. For each resident, LVN 2 stated the blood sugar check had already been completed and the ordered morning dose of insulin glargine had already been given before surveyor observation. Record review showed the physician orders directed insulin glargine to be administered at 6:00 AM for each of the three residents. LVN 2 confirmed that Resident 7 received 5 units at 3:31 AM, Resident 35 received 26 units at 3:31 AM, and Resident 46 received 32 units at 3:39 AM. LVN 2 acknowledged the insulin was administered approximately 2 hours and 21 minutes to 2 hours and 29 minutes earlier than the ordered time and stated insulin is considered a high-alert medication. The facility's policy titled Administering Medications, revised April 2019, stated medications are to be administered in a safe and timely manner, as prescribed, and within one hour of the prescribed time unless otherwise specified. LVN 2 confirmed the policy was not followed because the insulin was given too early. The DON also stated it is important for nursing staff to follow physician orders and administer medications within the facility's approved medication administration time frame. The report also identified another medication error in which Resident 82 received chewable aspirin 81 mg instead of the ordered enteric coated aspirin 81 mg.
Infection Control Program Not Maintained for Respiratory Equipment and Wheelchair
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained for three residents. Resident 32, admitted with COPD, acute respiratory failure, and dementia, was observed in the room with a nebulizer machine that had a brown crusted substance at the port site where the tubing connected to the machine. The nebulizer tubing was not in use and was hanging from a shelf in the room rather than being stored in a protective plastic bag. Resident 32 stated the treatment had just been completed, and an LVN acknowledged the equipment was not clean and that the tubing should have been stored in a clean protective bag when not in use. Resident 12, admitted with Parkinson's disease, HTN, behavior disturbances, and dementia, was observed in the lobby next to nursing station 3 with a wheelchair that had a dry brown crusted substance on the cushion, wheel area, and both side panels. The wheelchair was visibly soiled while in use by the resident. An LVN acknowledged the wheelchair was visibly soiled and stated it should be maintained in a clean and sanitary condition to prevent infection risk to the resident. Resident 13, admitted with COPD, acute respiratory failure with hypoxia, and centrilobular emphysema, had a physician order for continuous oxygen at 2 liters per minute via nasal cannula. The resident was observed with oxygen tubing loosely coiled and lying directly on the floor next to the bed while still connected to the oxygen concentrator, which was powered on at 1.5 liters per minute. The nasal cannula prongs and portions of the tubing were in direct contact with the floor, and a clear storage bag for breathing supplies was hanging from the concentrator. The RN confirmed the tubing was touching the floor and stated it should be stored in the plastic bag for infection control. The DON confirmed the facility policy was not followed for the respiratory equipment and wheelchair cleaning observations.
CNA Did Not Receive Required Annual In-Service Training
Penalty
Summary
The facility failed to ensure that 1 of 5 sampled CNAs, CNA 5, received the required in-service training of no less than 12 hours per year. During review of the facility’s required in-services log book with the DSD on May 21, 2026, CNA 5 was documented as having signed for eight in-services, including fall prevention, choking prevention, abuse recognition/intervention/reporting, oral care, standard/enhanced/droplet/airborne precautions, importance of oral hygiene, emergency response procedures, and safe repositioning techniques. Some entries listed no time, and the DSD stated during interview that CNA 5 did not meet the minimum required in-services.
Call Light Left Out of Resident Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for one sampled resident, Resident 49. Resident 49 was admitted with diagnoses including acute respiratory failure with hypoxia, COPD, and osteoarthritis. During a concurrent observation and interview on May 18, 2026, Resident 49 was observed lying in bed and stated, "I can't find my call light and this happens all the time." The call light was observed hanging off the side of the bed and out of reach, and Resident 49 was unable to independently notify staff for assistance or report a need for care. During a later observation and interview, CNA 4 confirmed that Resident 49's call light was hanging off the side of the bed and out of reach. CNA 4 stated that call lights should be within residents' reach and that it is important for residents to be able to request care. During interview and record review with the DON, the facility's policy titled "Answering the Call Light" was reviewed and stated that when a resident is in bed or confined to a chair, the call light should be within easy reach. The DON stated the expectation was for call lights to remain within residents' reach at all times and acknowledged the facility's policy was not followed.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an allegation of abuse involving an injury of unknown origin was reported to the State Survey Agency within the required time frame for one resident. The resident had paraplegia, cognitive communication deficit, and anoxic brain damage, and the MDS documented severe cognitive impairment with a BIMS score of 5 and maximal assistance needs. Physician orders included half side rails on both sides of the bed for safety and a fall mat at bedside to reduce injury risk from attempts to crawl out of bed. During observation, the resident was found in bed with a faded yellow-green circular discoloration around the right eye. The resident’s family member reported seeing a large black bruise under the right eye while visiting and stated the resident could not explain how it occurred. A CNA who assisted with care also observed the discoloration but did not report it. The DON stated staff were expected to immediately report new bruising or injuries of unknown origin to nursing for assessment and management notification. The facility’s policy required reports of injuries of unknown origin to be reported to local, state, and federal agencies as required, with immediate reporting defined as within 24 hours for allegations not involving serious bodily injury. The allegation was reported to the State Survey Agency 48 hours after the first observation of the possible abuse.
Bathroom Emergency Call Light Not Functioning
Penalty
Summary
The facility failed to ensure that a functioning resident call light was available in one resident’s bathroom. Resident 11 was admitted with paraplegia, cognitive communication deficit, and anoxic brain damage. On May 20, 2026, the resident was observed sitting upright in a wheelchair in his room and stated he wanted to use the restroom and was waiting for staff assistance. When the bathroom emergency call system was tested, pulling the emergency call cord and pressing the call button inside the bathroom did not activate any alarm, signal, or notification, and the bathroom call light system was found to be inoperable. During the same observation, the DON and Administrator came to the room and confirmed the restroom emergency call light was not functioning. The DON stated she was unaware of the problem and said maintenance would need to evaluate the system. The Maintenance Director later confirmed the bathroom call light was not functioning and stated Resident 11 frequently pulled on and damaged the call light equipment, requiring repairs on multiple occasions. Review of the resident’s MDS showed a BIMS score of 5 and that toileting hygiene was coded as dependent. The facility policy stated that the call light should be demonstrated to the resident, kept plugged in, and defective call lights should be reported promptly.
Failure to Provide Timely Written Response to Family Council Grievance
Penalty
Summary
The facility failed to provide a timely written response to a grievance submitted by the Family Council, as required by its own policy. According to the facility’s undated Family Council policy, the facility must respond in writing to written requests, concerns, or recommendations of the Family Council within 14 calendar days. The Long-Term Care Ombudsman submitted the Family Council minutes from an October 17, 2025 meeting to the former Administrator on November 9, 2025. As of an interview conducted on December 29, 2026, the facility was unable to provide any written response addressing the concerns raised in those minutes, and the DON acknowledged that no written response had been issued within the 14-day timeframe. Review of the Resident Council Town Hall Minutes dated November 20, 2025, showed that new concerns were discussed, including residents waiting two hours for an incontinence pad change and residents not being checked every two hours by staff. These concerns were part of the issues brought forward through the Family Council process. During the December 29, 2026 interview, the DON confirmed that a change in Administrators occurred during this period and stated that, due to this change, the facility did not provide the required written response within the policy’s 14-day requirement. The lack of timely written response affected all 99 residents residing in the facility, who are described as highly vulnerable.
Failure to Maintain Sufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as required by federal and state regulations. Over a six-day period, the facility did not meet the minimum required 3.5 direct care service hours per patient day (DHPPD), with documented shortfalls on each day. The Director of Nursing (DON) confirmed that the facility was short-staffed, particularly on the night shift, due to the recent resignation of three Certified Nursing Assistants (CNAs) and reliance on temporary staff. Facility records showed that on several days, the DHPPD fell significantly below the required threshold, with the lowest being 2.22 DHPPD. The facility's own policy, which mandates sufficient and competent staffing in accordance with resident care plans and facility assessment, was not followed during this period. This staffing deficiency had the potential to result in unmet psychosocial and physical needs, as well as safety concerns, for all 95 residents in the facility. The DON acknowledged awareness of the staffing shortfalls and confirmed that the required staffing levels were not maintained on the specified dates. The deficiency was identified during an unannounced complaint investigation related to quality of care, and the findings were corroborated through interviews and review of facility documentation.
Failure to Meet Required Nursing Staff Hours
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the required 3.5 direct care service hours per patient day (DHPPD) as mandated by regulation and the conditions of their staffing waiver. On multiple dates, including May 18, June 6, June 7, June 8, and June 9, 2025, the actual DHPPD fell below the required threshold, with the lowest recorded at 2.50 hours. This shortfall was confirmed through review of staffing assignments and acknowledged by both the Director of Staff Development (DSD) and the Director of Nursing (DON). During the investigation, it was reported by an LVN that a call light was left activated for 40 minutes without a Certified Nursing Assistant (CNA) present to respond, indicating a delay in addressing resident needs due to insufficient staffing. The DSD and DON both acknowledged the facility's failure to meet staffing requirements on the specified dates and recognized the importance of adequate staffing for resident safety and care. The deficiency had the potential to result in unmet psychosocial and physical needs, as well as safety concerns, for the facility's 95 residents. The facility's staffing waiver required a minimum of 3.5 DHPPD, and the failure to meet this standard was documented and confirmed by facility leadership during interviews and record reviews.
Plan Of Correction
3. We are scheduling registry CNAs to help with staffing requirements and pay for housing for staff. 4. Staffing coordinator & DSD will obtain availability schedule for staff to work during days off. 5. DSD and Administrator reiterated our attendance policy during our all staff meeting on June 5, 2025. D) How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. 1. The staffing coordinator/DSD will report during stand-up meetings the projected PPD for the day and the PPD calculation from the previous day and adjust staffing according to admission and discharge and if there are absences. 2. DSD will report findings during the monthly QA meeting if there are days that fall below the required PPD staffing levels and monitor for trends. 3. We will continue to reward and employee recognition for attendance and morale. We scheduled a shaved ice truck for all staff meetings as well as other local vendors to boost employee satisfaction/attendance. The Director of Nursing will report monitoring results to the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months or until substantial compliance is achieved and maintained. The QAPI Committee will make recommendations for additional interventions or modifications as needed. All corrective actions will be completed by 6/29/25.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident of suspected abuse or injury of unknown origin for one resident in accordance with its policy and regulatory requirements. The resident, who had diagnoses including Alzheimer's disease, osteoarthritis, benign prostatic hyperplasia, and lack of coordination, was found with redness and scratches on the face. Nursing notes documented a 1cm area of redness above the eyebrow, and the resident's power of attorney raised concerns about additional discoloration and marks, requesting an investigation. The incident was observed and discussed among staff, with the Director of Nursing (DON) and administrator being notified. Interviews with staff revealed that the certified nursing assistants (CNAs) and a licensed vocational nurse (LVN) noticed the injuries during their shifts, but there was uncertainty about how the injuries occurred. The LVN documented the findings and notified the DON, but did not believe the incident required immediate reporting or investigation, as the injuries did not appear intentional. The Director of Staff Development (DSD) collected statements from staff and communicated with the resident's sister, but the source of the injuries remained unknown. The facility's policy required immediate reporting of all suspected abuse or injuries of unknown origin to the state agency and local ombudsman, but this was not done within the required timeframe. The SOC341 form, which is used to report suspected abuse, was not submitted to the state agency until several days after the incident, and the facility was unable to provide the required 5-day investigation report. Interviews with the administrator and DSD confirmed that the reporting was delayed and that the investigation documentation was incomplete. The facility's failure to promptly report and thoroughly investigate the incident as required by policy and regulation constituted a deficiency.
Failure to Maintain Minimum Direct Care Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by 52 sampled days between October 2024 and March 2025 where the direct care service hours per patient day (DHPPD) fell below the required minimum of 3.5 hours. Interviews with CNAs revealed that staff shortages prevented them from providing necessary care, including 1:1 supervision for residents who wander, and that recent staff resignations had not been replaced. Management had discontinued the use of registry and travelers, further exacerbating staffing shortages, and both the Acting DON and DSD acknowledged ongoing difficulties in maintaining adequate staffing, particularly during sick calls and in the context of being in a rural area. Record reviews confirmed multiple dates with DHPPD below the required threshold, and the facility's own policy, which mandates adequate staffing to meet resident needs, was not followed. The Administrator and other leadership were aware of the staffing shortfalls and acknowledged that the facility did not meet the minimum required hours, despite having a staffing waiver that still required at least 3.5 DHPPD. The deficiency had the potential to result in unmet psychosocial, physical, and safety needs for the facility's 97 residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours, seven days a week, as required by their policy and regulatory standards. This deficiency was observed on multiple occasions during Fiscal Year 2025, Quarter 1, and in the timeframe from February 11, 2025, through March 11, 2025. Specifically, there was no RN scheduled on several Sundays, and on one occasion, an RN was scheduled for only four hours. The facility's policy, revised in August 2022, mandates that an RN provides services at least eight consecutive hours every 24 hours, seven days a week. However, the facility's schedules and staffing reports revealed gaps in RN coverage, with the Director of Nursing (DON) being on-call rather than physically present on some of these days. Interviews with facility staff, including RN #3 and the DON, confirmed the lack of RN coverage and the necessity of having RNs present to administer certain treatments that licensed vocational nurses (LVNs) are not trained to perform. The DON acknowledged the facility's failure to meet the regulatory requirement and noted that being on-call did not equate to being physically present in the facility. Acting Administrators also confirmed the need for RN presence in the building for the required hours and suggested that the issue could be resolved with better scheduling. The absence of RNs during these times indicates a failure to adhere to staffing requirements, potentially impacting the quality of care provided to residents.
Staffing Deficiency Due to Insufficient Direct Care Hours
Penalty
Summary
The facility failed to provide sufficient numbers of staff on three out of five sampled days, resulting in less than 3.5 direct care service hours per patient day (DHPPD). Specifically, on January 9, 11, and 12, 2025, the facility recorded DHPPD of 3.33, 3.31, and 3.15, respectively, which were below the required 3.5 DHPPD. This deficiency was identified through interviews and record reviews with the Administrator and the Director of Nursing (DON). The Administrator acknowledged the staffing issues and mentioned that they have refused to admit residents due to staffing concerns, while the DON confirmed that the facility's staffing policy was not followed. The facility had a staffing waiver in place, valid from July 1, 2024, to June 30, 2025, which required a minimum of 3.5 DHPPD. However, the waiver was not adhered to on the specified dates, as confirmed by the DON. The failure to meet the required staffing levels had the potential to result in unmet psychosocial, physical needs, and safety concerns for 93 residents. The DON emphasized the importance of having enough staff to ensure patient care is not affected and to provide adequate support for the working staff.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure that three residents received or were offered adequate fluids during the day and night, which could potentially compromise their health and safety. Resident 1, who has multiple diagnoses including contracture of the lower legs, thyrotoxicosis, and blindness in one eye, reported being left in soiled diapers and not having their urinal emptied. The resident also mentioned that requests for water refills were often ignored. Observations confirmed that the resident's water pitcher was empty, and the urinal was half full. Resident 2, diagnosed with hemiplegia, hypertension, and diabetes, expressed that it often took an hour or more to receive assistance after pulling the call cord. The resident stated that water was not regularly provided and had to be requested repeatedly. Similarly, Resident 3, who has congestive heart failure, hypertension, and muscle weakness, reported delays in receiving assistance and needing to call for water refills, as they were not automatically provided. Interviews with CNAs and the Kitchen Supervisor revealed inconsistencies in the water distribution process, with some staff members unaware of who was responsible for passing out water pitchers. The Director of Nursing acknowledged the issue, noting that the water pitchers should have been a specific color to indicate the shift responsible for hydration. The facility's policies on activities of daily living and hydration were reviewed, indicating a commitment to providing adequate hydration, which was not met in these instances.
Inadequate Response to Call Lights and Resident Care
Penalty
Summary
The facility failed to adhere to its Activities of Daily Living (ADLs) policy and procedure, resulting in inadequate care for three residents. Resident 1, who suffers from chronic pulmonary disease, idiopathic peripheral autonomic neuropathy, and cachexia, reported using the call light to request assistance but had to wait over an hour for help. This delay occurred during a time when the facility was short-staffed, and the resident was too weak to assist themselves. Resident 2, diagnosed with contractures, thyrotoxicosis, and blindness in one eye, was left in soiled diapers on multiple occasions. The resident reported that a CNA promised to return to change them but failed to do so, leaving them soiled from 2:00 AM until the morning shift at 9:00 AM. Additionally, the resident's urinal was not emptied, and requests for water were ignored, indicating a pattern of neglect in meeting basic care needs. Resident 3, who has hemiplegia and hemiparesis following a cerebral infarction, hypertension, and diabetes type II, also experienced significant delays in receiving assistance, often waiting over an hour after using the call light. The resident, along with their roommate, had to repeatedly request water, which was not provided consistently. Interviews with staff, including CNAs and the Director of Staff Development, confirmed issues with staffing and acknowledged that residents were left without timely care, which is considered neglect and a violation of the facility's policies.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to adhere to its food and nutrition services policy by serving meals that were not at an appetizing temperature to three sampled residents. Resident 1, who was admitted with a diagnosis of hyperlipidemia, reported that the food was not always served warm. Resident 2, diagnosed with bipolar disorder, stated that breakfast was often cold. Resident 3, admitted with muscle weakness, mentioned that the food was sometimes cold and barely warm on certain days. All three residents had no mental impairment as indicated by their Brief Interview for Mental Status (BIMS) scores. The Director of Nursing (DON) acknowledged that the issue of cold food might be related to staffing challenges, which can cause delays in food delivery. Additionally, it was noted that staff might not be closing the meal cart properly when delivering trays, leading to other trays getting cold too quickly. The facility's policy, dated October 2017, requires that food trays be inspected to ensure meals are provided at a safe and appetizing temperature, which was not adhered to in these instances.
Improper Garbage Disposal in Facility
Penalty
Summary
The facility failed to adhere to its food-related garbage disposal policy when four outdoor dumpsters were left open. This was observed during a concurrent observation and interview with the Maintenance Director, where it was noted that some dumpsters outside the facility were not closed. The Director of Nursing was later shown pictures of the open dumpsters and acknowledged the risk they posed as potential breeding grounds for rodents. The facility's policy, dated April 2006, requires that outside dumpsters be kept closed and free of surrounding litter. Additionally, the FDA Federal Food Code, 2022, emphasizes the importance of proper storage and disposal of garbage to prevent it from becoming an attractant and breeding place for insects. This failure had the potential to attract vermin, posing a significant health risk to the 89 clinically compromised residents residing in the facility.
Pest Control Deficiency Due to Discontinued Program
Penalty
Summary
The facility failed to adhere to its pest control policy, which resulted in a reported sighting of mice within the facility, affecting 89 residents. A resident reported seeing a mouse, described as a kangaroo mouse, inside the facility two days prior to the survey. This incident was reported to the maintenance staff. The Maintenance Director confirmed a recent occurrence of mice at the nursing station. The Director of Nursing acknowledged the presence of mice and stated that the facility's pest control program had been discontinued due to budget reasons. A review of the facility's pest control policy, dated May 2008, indicated that the facility was supposed to maintain an ongoing pest control program to keep the building free of insects and rodents.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to adhere to its policy and procedure for providing care and services to residents, specifically in ensuring that call lights are answered promptly. This deficiency was observed in the cases of four residents who experienced delays in receiving assistance with activities of daily living. Resident 1, who has a history of falling and difficulty walking, reported long wait times for call light responses. Similarly, Resident 2, diagnosed with muscle weakness, expressed concerns about staff availability and unresponsiveness to call lights. Resident 3, with osteoarthritis and walking difficulties, reported waiting up to 45 minutes for assistance and noted issues with meal service, including cold and delayed meals. Resident 4, also experiencing walking difficulties and weakness, reported waiting times of 20 to 45 minutes for staff response. During an interview, the Director of Nursing acknowledged the problem with call light response times, agreeing that residents should not have to wait 45 minutes for assistance. The facility's policy, dated October 2010, mandates that call lights should be answered as soon as possible. The failure to comply with this policy has the potential to jeopardize the health and safety of clinically compromised residents, as their requests for assistance were not addressed in a timely manner.
Failure to Follow Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to adhere to its policies and procedures in preventing, reporting, and investigating an allegation of suspected physical abuse involving a resident. The incident involved a Certified Nursing Assistant (CNA 1) who was employed before the completion of her background check. The background check was initiated two days after her hire date, contrary to the facility's policy that requires background checks to be completed before employment. This oversight was acknowledged by the Human Resources/Payroll department, the Director of Staff Development, and the Director of Nursing, all of whom were unaware of the premature hiring. The deficiency was further compounded by the facility Administrator's failure to respond promptly to an abuse allegation reported by the resident. The resident, who had a cognitive functioning score indicating full mental capacity, reported the inappropriate conduct by CNA 1 to the Administrator. However, the Administrator did not initiate an investigation or report the incident to the relevant state and local agencies within the required timeframe. The delay in action was attributed to the Administrator forgetting about the report, which was only addressed after being brought to attention by the ombudsman a week later. The facility's policies on abuse reporting and investigation were not followed, as confirmed by the Administrator and the Director of Nursing. The policies require immediate investigation and reporting of abuse allegations to local, state, and federal agencies. The failure to act promptly on the resident's report of abuse placed the resident and other vulnerable individuals at risk, highlighting significant lapses in the facility's adherence to its own procedures.
Failure to Suspend CNA After Alleged Abuse
Penalty
Summary
The facility failed to implement immediate protective measures following an alleged abuse incident involving a resident and a Certified Nurse Assistant (CNA). The incident was reported on April 24, 2024, when the resident informed the Administrator that the CNA had inappropriately touched her. Despite the facility's policy requiring immediate suspension of the accused staff member to protect residents, the Administrator admitted to forgetting to place the CNA on administrative leave. As a result, the CNA continued to have access to the resident and other vulnerable individuals in the facility for two consecutive days. The Human Resources/Payroll department was unaware of the need to remove the CNA from the schedule due to the ongoing investigation. This oversight allowed the CNA to work regular hours, maintaining contact with the resident and other residents, which was against the facility's policy. The facility's policy, as reviewed with the Director of Nursing and the Administrator, clearly states that any employee accused of abuse should be placed on leave with no resident contact until the investigation is complete. The Administrator acknowledged that the facility did not adhere to this policy, which posed a risk of further abuse, neglect, exploitation, or mistreatment of the residents.
Medication Administration and Call Light Response Deficiencies
Penalty
Summary
The facility failed to administer medications to Resident 1 in a timely manner as prescribed by the physician. Resident 1, who was admitted with a diagnosis of unspecified peripheral vascular disease, reported a decrease in the quantity of pills taken in the morning. An error occurred at the pharmacy, and although the medications were delivered to the facility, they were not placed in the medication cart drawer for administration. This resulted in missed doses of Apixaban, Tamsulosin, Diltiazem HCL, Furosemide, and Digoxin over several days in May 2024. Interviews with the nursing staff revealed a breakdown in communication and procedure adherence, leading to the failure to administer the medications as per the Medication Administration Record (MAR). Additionally, the facility did not respond promptly to call lights for three residents, including Resident 1, Resident 2, and Resident 3. Resident 1 reported waiting times of up to 16 hours for assistance during the night, while Resident 2 and Resident 3 experienced delays of up to two hours. These delays were particularly problematic during nighttime hours, from 8:00 PM to early morning. The Director of Nursing acknowledged the poor response times, attributing them to insufficient staffing levels, with only four Certified Nursing Assistants (CNAs) available during the night shift. The facility's policy and procedure documents for administering medications and answering call lights were not followed, leading to these deficiencies. The failure to administer medications as prescribed and the delayed response to call lights posed potential risks to the health and safety of the residents involved, who were clinically compromised due to their medical conditions.
Delayed Reporting of Suspected Abuse by CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA 1) reported an allegation of suspected physical abuse towards a resident (Resident 1) within the timeframe specified by their policy and procedures. CNA 1 was aware of the alleged abuse on April 2, 2024, but did not report it to the facility administration until April 4, 2024. This delay hindered the facility's ability to promptly investigate the allegation and potentially exposed Resident 1 to continued risk of abuse. The incident involved CNA 1 overhearing a conversation about another staff member allegedly abusing Resident 1 by splashing water in her face, pulling her hair, and hitting her in unnoticeable areas while laughing at her distress. Resident 1 was admitted with diagnoses including unspecified dementia and adjustment disorder with mixed anxiety and depressed mood. The resident had a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment. The facility's policy required immediate reporting of suspected abuse to the administrator and other authorities, defining 'immediately' as within two hours for allegations involving abuse or serious bodily injury, or within 24 hours for other allegations. The Director of Nursing confirmed that CNA 1 should have reported the incident immediately, as per the facility's policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bishop Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.