Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Noa Home For Senior Citizens during CMS and state inspections, most recent first.
Failure to Submit PBJ Staffing Data: The facility failed to submit PBJ staffing data to CMS for a quarter, resulting in a report showing no submitted data, excessively low weekend staffing, no RN hours, and no licensed nursing coverage 24 hours/day. The Resident Account Representative stated they were responsible for the submission and did not submit the data, and the NHA acknowledged the omission.
Missing Annual CNA Competency Training: The facility failed to ensure that four of five CNAs reviewed had annual competency training and documented skills validation. Record review showed multiple CNAs lacked current dated competency documentation, and the HR Manager stated CNAs must have annual competency training; the NHA acknowledged the identified CNAs did not have it. The FA also required annual evaluation of nurse aide competencies.
The facility failed to complete annual performance reviews for 3 CNAs out of 5 reviewed. Record review showed that the identified CNAs had not received performance evaluations at least every 12 months, and the HR Manager stated staff have annual performance reviews while the NHA acknowledged the missing evaluations. The FA stated that annual performance evaluations for all staff are stored in the personnel file.
Infection control practices were not consistently followed during resident care and surveillance. A CNA passed water between rooms, including a contact precaution room, without hand hygiene, while the IP had not completed the monthly infection surveillance line listing and some resident infection documentation was incomplete or inaccurate. A resident on droplet precautions for influenza A had an open room door and an RN entered without eye protection, another resident’s catheter bag dragged on the floor, and shower equipment was observed damaged and not in cleanable condition.
Failure to address grievances for missing resident clothing: Three residents reported missing clothing items after laundry, including jeans, a sweater, and a nightgown, but no grievances were found in the log. The AD stated missing clothing was not written up as a grievance and the NHA said there was no form or procedure for missing items, with no communication to administration about the losses.
Failure to Provide Bed Hold Notice: A resident with a hip fracture was sent to the hospital after a fall, but the EMR did not show that a bed hold notice was provided to the resident or responsible party. The Resident Account Representative stated the facility does not give the bed hold policy to Medicaid residents when they go to the hospital, and the NHA acknowledged the notice had not been given, despite facility policy requiring bed hold information within 24 hours of a temporary absence.
Failure to Maintain Orders and Documentation for Indwelling Urinary Catheter: A resident admitted with urinary retention had an indwelling urinary catheter in place, but the EMR lacked a physician order identifying the catheter and balloon size. The resident was unsure why the catheter was present, and although orders existed to change the Foley and obtain a UA/C&S, the progress notes did not document catheter removal or reinsertion reflected on the TAR. Nursing staff and the DON acknowledged that catheter orders should be in place.
Bed rails were installed for a resident with stroke, aphasia, hemiplegia, and severe cognitive impairment without a documented assessment, physician order, or informed consent. Staff and the NHA could not locate a bed rail policy, and interviews confirmed no bed rail consent or order was present in the record. The resident could grasp one rail with one hand, while the other rail was only used when staff placed the resident’s paralyzed hand on it.
A resident was observed with an empty med cup on the floor and another cup on the bedside table containing a pill after refusing oxycodone because it caused constipation and requesting Tylenol instead. An LPN had dispensed the oxycodone earlier, but the med was not consumed at the time it was given, and the NHA confirmed the resident had no order to self-administer meds and that meds should not be left at the bedside.
A resident with severe cognitive impairment exited the facility unsupervised and was outside for over ten minutes before being located and returned by staff, following a visitor's alert. Staff interviews revealed that alarms were triggered but the response was insufficient, with some staff not fully searching the area or lacking training on elopement procedures. The facility's policy to prevent wandering and elopement was not effectively followed.
A facility failed to ensure staff wore PPE as required for a resident under Enhanced Barrier Precautions (EBP). The resident, with ALS and a feeding tube, was transferred by two CNAs who did not wear gowns, and one did not wear gloves or perform hand hygiene. The Hoyer lift used was not sanitized before or after use. Interviews confirmed the failure to follow infection control procedures, despite prior training on EBP protocols.
The facility failed to ensure proper cleaning and sanitization of shared equipment, such as sit-to-stand and Hoyer lifts, which were observed to be heavily soiled with dirt, debris, and grime. Staff interviews revealed that CNAs and other staff were responsible for cleaning the equipment, but sanitizing wipes were not easily accessible, contributing to the deficiency. The facility's policy required adherence to CDC and OSHA standards, but observations indicated a lack of compliance.
A facility failed to ensure proper assessments, physician orders, and medical justification for the use of a merry walker as a restraint on a resident with vascular dementia. The resident used the merry walker without a physician's order, and there was a delay in obtaining consent and updating the care plan. The facility's policy lacked guidance on restraint use, assessments, and consents.
A facility failed to complete a recapitulation of stay for a resident discharged after surgical aftercare. The resident's EMR lacked a discharge plan, recapitulation of stay, and medication reconciliation. Interviews with staff, including an RN, LPN, and DON, revealed that discharge summaries were expected but not present, and the DON acknowledged the absence of a required recapitulation of stay.
A resident with obstructive sleep apnea and asthma had their CPAP mask and tubing improperly stored without protective covering, and oxygen tubing was in contact with the floor. Staff interviews revealed a lack of awareness of cleaning and storage policies, and the DON acknowledged the infection control concern. Facility policies for cleaning and storing respiratory equipment were not followed.
A resident with severe cognitive impairment and chronic pain was involved in a misappropriation incident where an LPN diverted morphine sulfate. The morphine, prescribed for pain management, was found discolored, and camera footage showed the LPN accessing and tampering with the medication without documented need. The facility concluded the LPN diverted the medication.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate PBJ staffing information to CMS based on payroll and other verifiable and auditable data. Review of the CMS PBJ Staffing Data Report for FY Quarter 1 2026 (October 1-December 31) showed Failed to Submit Data for the Quarter, One Star Staffing Rating Excessively Low Weekend Staffing, No RN Hours, and Failed to have Licensed Nursing Coverage 24 Hours/Day. During interview, the Resident Account Representative stated that they were responsible for submitting the PBJ information to CMS and did not submit the information for that quarter. The NHA also acknowledged that the PBJ data for the first quarter was not submitted.
Missing Annual CNA Competency Training
Penalty
Summary
The facility failed to ensure that four of five CNA staff reviewed had the required yearly competency trainings, including demonstration of the skills and techniques necessary to care for residents. Personnel record review showed CNA C, hired 10/11/22, had no dated competency skills documentation since 3/11/25; CNA D, hired 7/13/23, had no dated competency skills documentation since 7/24/24; CNA E, hired 5/21/24, had no dated competency skills documentation since 5/21/24; and CNA G, hired 3/8/22, had no dated competency skills documentation since 6/11/24. During interview, the Human Resource Manager stated that CNAs must have annual competency training, and the Nursing Home Administrator acknowledged that the identified CNAs did not have annual competency training. The Facility Assessment dated 3/26 also stated that annual evaluation of identified competencies for nurse aide staff was required.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for three Certified Nurse's Aides out of five reviewed, with each of the identified CNAs lacking a performance evaluation at least every 12 months. Personnel record review showed that CNA C, hired on 10/11/22, had no performance review since 3/11/25; CNA D, hired on 7/13/23, had no performance review since 9/30/23; and CNA G, hired on 3/8/22, had no performance review since 9/21/23. During interviews, the Human Resource Manager stated that staff have annual performance reviews, and the Nursing Home Administrator acknowledged that the identified CNAs did not have annual performance evaluations. The Facility Assessment dated 3/26 stated that annual performance evaluations for all staff are stored in the personnel file.
Infection Control Failures During Resident Care and Surveillance
Penalty
Summary
The facility failed to implement infection prevention and control program components during multiple observed events. During a water pass on the 100 hall, a CNA was observed carrying used water mugs in bare hands from one resident room to another without performing hand hygiene, including when entering and exiting a room with a Contact Precaution sign posted outside the door. The CNA also handled clean water mugs and used mugs without hand hygiene between rooms, and later acknowledged that hand hygiene had not been performed while moving between resident rooms, including the contact precaution room. The infection preventionist did not have the April 2026 infection surveillance line listing or mapping completed at the time of review and stated the monthly line listing had not yet been done. Review of resident infection surveillance documentation showed one resident’s infection had been identified in March 2026 even though it was being reviewed in April, and another resident was listed in the EMR dashboard without completed paperwork or established criteria. The infection preventionist stated one entry was an error and that another resident’s paperwork had not yet been filled out. Resident #27 was observed under droplet precautions for influenza A, but the room door was wide open during observations and staff did not consistently follow the posted transmission-based precaution signage. One RN entered the room without eye protection despite the signage indicating PPE requirements. Another resident with an indwelling catheter was observed propelling a wheelchair while the catheter bag dragged on the floor with urine visible in the bag. In the spa shower room, a shower chair seat cover had a hole exposing foam, and bathing straps and back supports were observed with cracked, frayed, and exposed material.
Failure to Address Grievances for Missing Resident Clothing
Penalty
Summary
The facility failed to respond to grievances related to missing clothing for three residents who were reviewed for grievances. During a resident group meeting, one resident reported that two pairs of jeans and a nightgown had been missing for about 6 months after being sent to laundry. Another resident reported that a turquoise sweater had been missing for at least 2 months after being sent to laundry. A third resident reported that a brand-new nightgown had gone missing after being sent to laundry and stated the resident did not know the facility placed lost items on a table for residents to search through. Review of the grievance log did not show any grievances for the missing clothing reported by these residents. The AD stated that when clothing goes missing, a grievance sheet is not completed and that the facility does not do anything like that. The AD also stated the missing items had not been reported to the NHA. The NHA stated the facility did not have a form or procedure for missing items and had not heard about the missing clothing, noting there was a lack of communication regarding the items. The facility’s policy on missing items stated that efforts would be made to locate missing items and/or provide restitution when warranted, and a grievance policy was requested but not provided prior to exit.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice for one resident who was hospitalized. Resident #11’s MDS showed an admission to the facility on 3/24/25 with diagnoses including hip fracture. The EMR showed the resident sustained a fall and was discharged to the hospital on 3/17/26, but the record did not show that a bed hold policy had been provided to the resident or responsible party. During interview, the Resident Account Representative stated the facility does not give the bed hold policy to residents on Medicaid when they go to the hospital, and the NHA acknowledged that a bed hold policy had not been given to the resident or responsible party. The facility policy titled Bed Holds and Readmission stated that bed hold information will be provided to the resident and/or responsible party within twenty-four hours of the temporary absence.
Failure to Maintain Orders and Documentation for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter was medically necessary and that physician orders were in place for one resident, who was admitted with diagnoses including retention of urine and fracture of the right tibia. On observation, the resident was found in her room with a urinary catheter bag hanging on the side of her bed and stated she was not sure why she had the catheter and thought it was for convenience. Review of the electronic medical record showed no physician order for the indwelling urinary catheter indicating the catheter size and balloon size to secure the catheter in the bladder. The record also showed physician orders dated 4/20/26 to change the Foley catheter and obtain a urine sample for UA and C&S, and a 4/25/26 one-time order for catheter change after 24 hours of Fluconazole therapy, but the resident’s progress notes lacked documentation of removal or reinsertion of the catheter as reflected on the April 2026 TAR. During interviews, nursing staff and leadership acknowledged that orders should be present for indwelling catheters, including balloon size and catheter size, and the NHA stated the catheter should have been removed after the resident arrived at the facility. The facility policy stated indwelling urinary catheters are to be used only when medically necessary and maintained according to evidence-based guidelines.
Bed Rails Installed Without Assessment, Order, or Consent
Penalty
Summary
The facility failed to assess the risk of entrapment, review bed rail risks and benefits with the resident or resident representative, obtain informed consent, and obtain a physician order before installing bilateral quarter bed rails for one resident. During observation, the resident was lying in bed with the head of the bed elevated to approximately 45 degrees, a breakfast tray was on an overbed table, and the resident was unable to eat independently. The resident did not respond visually or verbally to conversational questions. The resident’s MDS showed diagnoses including stroke, heart failure, atrial fibrillation, aphasia, and hemiplegia. The assessment also documented no spoken words, rare or no understanding when spoken to, severely impaired cognitive skills for daily decision making, and dependent assistance for eating, oral hygiene, toileting, bathing, transfers, and bed mobility. The resident used a wheelchair for mobility, and no restraint or alarm use was documented in the MDS. The medical record review and staff interviews showed no bed rail assessment, no physician order, and no consent form for the bed rails. A nurse supervisor stated there should have been a physician order and consent, but none could be found in the hard chart or EMR. During repositioning, the resident could use the right bed rail with the left hand, but the left bed rail was only used when staff placed the resident’s paralyzed hand onto it. The nursing home administrator confirmed the facility did not have a bed rail policy, and the restraint policy in use required assessment, physician order, and consent before restraint use.
Narcotic Left at Bedside Without Ensuring Consumption
Penalty
Summary
The facility failed to ensure a narcotic medication was stored and/or consumed in a safe and secure manner for one resident. Resident #23 was observed lying in bed with an empty medication cup on the floor and a second medication cup on the bedside table containing a small single round white pill. When asked about the medication, the resident stated she did not want to take it because oxycodone makes her constipated and said her pain was at a 4 and she wanted Tylenol instead. During interview, an LPN stated she had not dispensed the oxycodone and identified another LPN as the nurse who had dispensed it. Review of the narcotic administration record showed the oxycodone had been dispensed at 4:47 AM. The NHA stated medications should not be left at the bedside and nurses are to ensure medications are consumed at the time they are dispensed. The NHA later confirmed the resident did not have a physician order to self-administer medications. The facility policy stated medications are to be given as prescribed, safely, and in a timely manner while observing resident rights.
Resident Elopement Due to Inadequate Supervision and Response
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, including Alzheimer's disease and dementia, was able to exit the facility unsupervised. The resident, who was known to wander and had a history of attempting to leave through various exit doors, left the dining room, proceeded down the hall, and exited the facility. The resident was outside for approximately 13 minutes before being located and returned by staff, after a visitor alerted them to the resident's presence in the parking lot. The facility's records and staff interviews confirmed that the resident's cognitive skills were severely impaired, and the resident rarely made decisions or was understood. Staff interviews revealed that alarms sounded when the resident exited, but initial responses were inadequate. Staff members checked the immediate area but did not conduct a thorough search outside or down the street. One CNA stated she was not trained on what to do in the event of an elopement. The incident was only fully recognized after a visitor reported seeing the resident outside, at which point staff located the resident about half a block from the facility. The facility's policy required maintaining a safe environment and preventing elopement, but these measures were not effectively implemented in this case.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was worn by staff as required when caring for a resident under Enhanced Barrier Precautions (EBP). The resident, who was cognitively intact and had a diagnosis of Amyotrophic Lateral Sclerosis (ALS), was observed being transferred by two Certified Nursing Assistants (CNAs) using a Hoyer lift. The CNAs did not wear gowns, and one CNA did not wear gloves or perform hand hygiene before and after the transfer, as required by the EBP protocol. The Hoyer lift was not sanitized before or after use, and the CNA re-entered the resident's room without performing hand hygiene. Interviews with the CNAs and a Licensed Practical Nurse (LPN) confirmed the failure to follow proper infection control procedures. The LPN stated that the resident was on EBP due to having a feeding tube, and all staff should use proper hand hygiene, gloves, and a gown when providing care. The CNAs acknowledged their failure to adhere to the EBP protocol, with one CNA admitting to not paying attention to the signage and expressing regret for the oversight. The facility had provided training on the EBP protocol, but the CNAs did not follow the procedures during the observed incident.
Failure to Clean and Sanitize Shared Equipment
Penalty
Summary
The facility failed to ensure that resident shared equipment was properly cleaned and sanitized, compromising the residents' right to a safe, clean, and comfortable environment. Observations revealed that multiple sit-to-stand lifts and Hoyer lifts were heavily soiled with dirt, debris, food crumbs, and grime. The padded areas of these lifts, which come into contact with residents, were noted to have dried, crusted substances, indicating a lack of proper cleaning and sanitization after use. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Patient Care Aide (PCA), highlighted that the responsibility for cleaning shared equipment fell on the Certified Nurse Aides (CNAs) and any staff using the equipment. However, the sanitizing wipes required for cleaning were not readily accessible, as they were stored in locked medication storage rooms or soiled linen rooms. This lack of accessibility may have contributed to the failure to clean the equipment properly, as staff had to request access to the wipes, which was not frequently done. The facility's policy on cleaning and disinfecting resident shared equipment was reviewed, revealing that equipment should be cleaned and disinfected according to CDC recommendations and OSHA standards. Despite this policy, the observations and staff interviews indicated a gap in adherence to these procedures, as evidenced by the consistently soiled condition of the equipment. The deficiency was not addressed with any corrective actions or follow-up measures within the report.
Failure to Ensure Proper Use of Physical Restraints
Penalty
Summary
The facility failed to ensure appropriate assessments, physician orders, and medical justification for the use of physical restraints on a resident. The resident, who was diagnosed with vascular dementia with agitation, was observed using a merry walker, which is a type of restraint, without a physician's order. The resident's electronic medical record indicated the use of a chair that prevents rising restraint less than daily, but there was no documentation of a physician's order for the merry walker. The Director of Nursing confirmed that the resident was first given a merry walker in November 2024, but there was no resident representative consent signed until January 2025. Additionally, there was a delay in updating the resident's care plan to include the use of the merry walker, and no completed assessments were found. The facility's policy on restraints did not provide guidance on determining the need for a physical restraint, obtaining physician orders, conducting assessments, obtaining consents, or updating care plans.
Failure to Complete Recapitulation of Stay for Discharged Resident
Penalty
Summary
The facility failed to ensure a recapitulation of stay was completed for a resident discharged to the community. The resident, who was admitted for surgical aftercare following an intestinal obstruction, was discharged after a short-term rehabilitation stay. Upon review of the resident's electronic medical record (EMR), it was found that there was no discharge plan, recapitulation of stay, or reconciliation of pre- and post-discharge medications documented. Interviews with facility staff, including a Registered Nurse (RN), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), revealed that each discipline was expected to include a discharge progress note in the EMR. However, the staff were unsure why the expected discharge summaries were not present in the resident's EMR. The DON confirmed that a discharge summary by discipline was expected, but an official recapitulation of stay was not part of the facility's discharge process, despite regulations requiring it.
Improper Cleaning and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage and proper cleaning of respiratory equipment for a resident diagnosed with obstructive sleep apnea and asthma. The resident's CPAP mask and tubing were repeatedly observed on the dresser without protective covering, and the supplemental oxygen tubing and nasal cannula were in direct contact with the floor. The resident reported that the respiratory equipment was supposed to be cleaned daily, but staff did not routinely perform this task. The facility's policy required the CPAP equipment to be cleaned regularly, and oxygen tubing to be stored in a plastic bag when not in use, but these procedures were not followed. Interviews with facility staff revealed a lack of awareness and understanding of the cleaning and storage policies for respiratory equipment. A CNA was unfamiliar with the facility's cleaning or storage policy, and an RN was unaware of the manufacturer's instructions for cleaning the equipment. The Director of Nursing acknowledged that the CPAP tubing should be cleaned after each use and more thoroughly once a week, but noted that the order to clean per manufacturer's instructions was unclear and not accessible to floor staff. The DON also recognized that the improper storage of the CPAP mask and oxygen cannula posed an infection control concern, increasing the risk of respiratory illness.
Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication for a resident with severe cognitive impairment and multiple diagnoses, including cancer and chronic pain. The resident was prescribed morphine sulfate for pain management, but an incident was reported when a nurse noticed the morphine solution was discolored. The facility's investigation revealed that the morphine concentrate, which should have been blue, appeared clear, indicating possible tampering. The resident did not show signs of increased pain or distress during this time. Further investigation, including a review of camera footage, showed that an LPN repeatedly accessed the morphine vial and syringes, taking them into the nurses' lounge or bathroom and then returning them to the medication cart. The LPN had no documented need to administer morphine during the observed period, leading the facility to conclude that the LPN diverted the medication. The facility's policy on abuse and misappropriation was referenced, indicating that such incidents are reviewed by the QAPI committee for potential improvements.
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Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — 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
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Illustrative
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Nursing homes near Escanaba
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Park Village | 0.4 mi | ★★★★★ | 2 | 0 |
| Christian Park Health Care Center | 0.4 mi | ★★★★★ | 5 | 0 |
| Pinecrest Medical Care Facility | 21.3 mi | ★★★★★ | 0 | 0 |
| Roubal Care And Rehabilitation Center | 34.1 mi | ★★★★★ | 0 | 0 |
| Serenity Spring Senior Living At Scandia Village | 38.7 mi | ★★★★★ | 3 | 0 |
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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.