Bishop Noa Home for Senior Citizens

Inspectors wroteBased on interview and record review the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid) resulting in inaccurate reporting of staffing levels with the potential to affect all 69 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure four Certified Nurse Aides (CNA's) [ C D E and F] of five CNA's reviewed for competencies had the required yearly competency trainings, including demonstration in skills and techniques necessary to care for residents.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual performance review for three Certified Nurse's Aides (CNA's) out of five reviewed at least every 12 months.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control program components as evidenced by the failure to:Perform appropriate hand hygiene during water pass,Ensure an ongoing, systematic collection and analysis of infection surveillance data,Properly don personal protective equipment (PPE) and ensure droplet precautions were implemented for Resident #27,Maintain a Resident catheter in a hygienic manner, andEnsure resident care equipment was maintained in a cleanable condition for use. These deficient practices resulted in the potential for the spread of infectious organisms and disease within the facility with the potential to affect all residents within the facility.

Inspectors wroteBased on interview and record review, the facility failed to respond to grievances for three Residents (#31, #43 and #52) of eight residents reviewed for grievances.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notice for one Resident (#11) of four residents reviewed for hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an indwelling urinary catheter device was medically necessary and physician orders were in place for one Resident (#23) of two residents reviewed for catheters.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the risk of entrapment, review bed rail risks and benefits with the resident/resident representative and obtain consent and a physician order prior to the installation of bed rails for 1 Resident (#19) of 1 resident reviewed for bed rail safety. This deficient practice resulted in the potential for bed entrapment and risk of injury and death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a narcotic medication was stored and or consumed in a safe and secure manner for one Resident (#23) of seven residents reviewed for medication storage. Findings Include:Resident #23 (R23)On 4/29/26 at 7:30 AM, an observation was made of R23 lying in bed in her room. R23 had an empty medication cup on her floor upside down. R23 had a second medication cup on her bedside table with a small single round white pill inside. R23 was asked about the medication left in the cup and replied, I did not want to take it. I get all bound up if I take my oxycodone. R23 was asked if she was in any pain and what she would like to take for her pain and replied, My pain is at a 4 and I would like some Tylenol. [...]

Inspectors wroteThis citation pertains to intake MI00152541 Based on interview and record review, the facility failed to provide adequate supervision for one Resident #1 (R1) of one resident reviewed for elopement. This deficient practice resulted in R1 leaving the facility unattended with the potential for fall and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed ensure personal protective equipment (PPE) was worn by staff as required when caring for 1 Resident (#21) of 3 residents, reviewed for Enhanced Barrier Precautions (EBP). This deficient practice resulted in the potential for infection, communicable disease and multi-drug resistant organism transmission.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident shared equipment was properly cleaned and sanitized.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate assessments, physician orders, and medical justification, for restraints that were in place for one Resident (R49) of one resident reviewed for restraints.

Inspectors wroteBased on interview and record review, the facility failed to ensure a recapitulation of stay was completed for one Resident (#66) out of one resident reviewed for for discharge to the community. Findings Include: Resident #66 (R66) Review of R66's electronic medical record (EMR) revealed admission to the facility on 1/14/25 for surgical aftercare following an intestinal obstruction. R66 was discharged from the facility on 1/30/25 following a short-term rehabilitation stay. Review of R66's EMR revealed no discharge plan, recapitulation of stay, nor reconciliation of pre- and post-discharge medications. On 3/6/25 at 9:28 AM, an interview was conducted with Registered Nurse (RN) M regarding discharge expectations. RN M stated each discipline was supposed to include a discharge progress note in the EMR. RN M was unsure why R66 did not have the expected discharge summaries in their EMR. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary storage and proper cleaning of respiratory equipment for one Resident (#59) of one resident reviewed for respiratory services.

Inspectors wroteThis citation pertains to Intake:MI00147670 Based on observation, interview, and record review, the facility failed to prevent the misappropriation of narcotic medication for one Resident (R1) of six residents reviewed for misappropriation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety as evidenced by failing to ensure that potentially hazardous food was labeled, dated, and cooled according to facility policy and food code guidelines. This deficient practice had the potential to result in food borne illness among any or all the 57 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues, placing all 57 residents in the facility at risk for quality care concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an infection prevention and control program to prevent the hospitalization of one Resident (R205) and prevent the spread of infectious organisms for eight Residents (R16, R47, R42, R13, R205, R32, R31, and R33) of eight residents reviewed for infection prevention and control as evidenced by failure to: 1. Post isolation precaution signage timely for residents with indwelling medical devices and/or wounds. 2. Post isolation precautions procedures in accordance with facility policy and/or standards of practice for residents with known contagious illnesses. 3. Post appropriate Personal Protective Equipment (PPE) information for residents diagnosed with infectious illnesses. 4. Develop care plans for residents with known contagious, infectious illness. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate less than 5 percent when eight medication errors were observed out of 25 medication pass opportunities. This deficient practice resulted in a 32 percent medication error rate, the potential for medication to not be administered, and medications provided in a manner that was inconsistent with physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure insulin pens were not stored past the 28-day manufacturer storage recommendation in one medication cart out of two carts reviewed for medication storage. This deficient practice resulted in the administration of expired insulin, and the potential for reduced effectiveness and elevated blood sugars.

Inspectors wroteBased on interview and record review the facility failed to ensure communication/documentation between the facility and the hospice provider occurred to ensure coordination of care for one Resident (R26) of one Resident reviewed for hospice services. This deficient practice resulted in the potential for a lack of coordination of comprehensive services and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe wheelchair securement in the transport van for one Resident (R2) of three residents reviewed for safety and supervision. This deficient practice resulted in the potential for injury when resident wheelchairs were not properly secured, per manufacturer's instructions, in the facility transport van. This deficiency has the potential to affect all residents transported via wheelchair in the facility van.