Bishop Spencer Place, Inc, the

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an appropriate infection control program to include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and others; and failed to ensure appropriate infection control practices were maintained during one sampled resident's (Resident #21) wound care treatment out of 14 sampled residents. The facility census was 53 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients/residents) program was in place which had the potential to affect all residents in the facility. The facility census was 53 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their facility Criminal Background Investigations policy showed a check of the Nurse Aide (NA) Registry would be completed for all potential facility employees and volunteers; subsequently, three facility employee records (Employees C, D, and E) out of five facility employee records sampled did not have NA Registry background screenings completed prior to hire, potentially affecting any resident at the facility. The facility census was 53 residents. Review of the facility's Criminal Background Investigations, HR-008 policy, revised 2/28/22, showed:-Applicants will complete the Post-Offer Credit Report Act (FCRA) Disclosure and confirm their understanding of the criminal background check requirement. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive care plans were up to date and reflected three sampled residents (Resident #50, #57, and #73) current status out of 14 sampled residents. The facility census was 53 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document the residents [NAME] Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) for a resident on hospice services by not marking section J item number J1400 for prognosis less than six months to live for one sampled resident (Resident #54) out of 14 sampled residents the facility census was 53 residents. Review of the facility policy titled [NAME] Place (BSP) Minimum Data Set revised 12/2/25 showed:-A Registered Nurse (RN), also known as the MDS Coordinator, would be responsible for conducting and coordinating the development, completion, and submission of the MDS Assessment for each resident.-The individual who completed a portion of the MDS must have certified the accuracy of that portion of the assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR a requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one sampled resident (Resident #57) was reviewed for accuracy and updated after admission to the facility out of 14 sampled residents. The facility census was 53 residents. A policy related to PASRRs was requested and not received prior to exit on 1/9/26.1. Review of Resident #57's PASRR Level One Screening dated 9/1/21 showed:-The screening had been completed by a local hospital prior to the resident's admission to the facility.-The resident did not show any signs or symptoms of a major mental disorder.-The resident had never been diagnosed with a major mental disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident's (Resident #21) wound care orders were followed during observation of his/her wound care out of 14 sampled residents. The facility census was 53 residents. A policy related to following physician orders was requested and not received prior to exit on 1/9/26.1. Review of Resident #21's admission Record showed the resident readmitted to the facility on [DATE] with a diagnosis of Osteomyelitis (an infection and inflammation of bone tissue). Review of the resident's Order Summary Report dated January 2026 showed:-The resident had a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #58) out of 14 sampled residents had bed assist devices installed in a timely manner, clarified if the resident needed a right side bed assist bar or bilateral bed devices, and failed to ensure the resident's care plan identified specifically the equipment needed to improve the resident's independence with bed mobility and transfers. The facility census was 53 residents. Review of the facility's Bed Rails Policy, revised 12/24/25 showed:-Bed rails will also refer to grab bars, halo bars, assist bars, and safety rails (adjustable metal or rigid plastic bars that attach to a bed). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide catheter care, document catheter care, or refusal of catheter care for one sampled resident (Resident #33) out of 14 sampled residents. The facility census was 53 residents. Review of facility policy titled Management of Foley Catheters revised 12/2/2025 showed:-Document the care in the electronic medical record. 1. Review of Resident #33's Admissions Record showed the resident's readmission date of 11/11/25 with the following diagnoses:-Urinary tract infection.-End stage renal disease (ESRD is when you have permanent kidney failure that requires a regular course of dialysis or a kidney transplant). Review of the resident's Treatment Administration Record (TAR) dated November 2025 showed 13 out of 38 opportunities where catheter care was not documented. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free from a significant medication error. On 7/12/24 Resident #1 was administered 5 milliliters (ml) (100 mg (milligrams)/5 ml) oral solution of morphine concentrate (a opiate medicine used to treat moderate to severe pain) instead of the physician ordered 0.5 ml (10 mg) by mouth PRN (as needed) every 6 hours for pain. Narcan (a medicine that can save someone from a prescription Opioid medicine overdose) was ordered by the physician due to the dosage being 10 times the amount ordered and administered. The facility census was 48 residents. The Administrator was notified on 7/24/24 at 2:12 P.M., of an Immediate Jeopardy (IJ) which began on 7/12/24. The IJ was removed on 7/24/24 as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Resident #2 and #3) were free from medication errors, out of 10 sampled residents. On 3/25/24 Resident #2 was given the wrong medication when the Certified Medication Technician (CMT) handed the medication to Licensed Practical Nurse (LPN) A, who then administered the medication to the wrong resident, and on 4/4/24 Resident #3 was given his/her medication twice. A family member had given the medication to the resident and it was not signed out on the Medication Administration Record (MAR). When the resident returned to the facility the medication was given to the resident for the second time. The facility census was 48 residents. Review of the facility's Medication Administration policy, dated 6/29/2023, showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to keep the walk-in freezer floors clean; to retain operable thermometers in all freezers to confirm adequate temperature ranges; to maintain sanitary food preparation equipment; to change the deep fryer oil in a timely manner; and to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination), in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 53 residents with a licensed capacity for 57 residents at the time of the survey. 1. Observation on 1/31/24 between 9:07 A.M. and 11:30 A.M. during the initial kitchen inspection showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to disperse remaining resident trust account funds and to convey within 30 days of death, a final accounting of the resident trust fund account to the individual or probate jurisdiction administering the resident's estate in accordance with state law after the residents expired for three sampled residents (Residents #106, #107, and #108) out of three expired residents sampled for disbursement of funds. The facility census was 53 residents. Review of the facility's policy titled Management of Residents' Funds dated 2024 showed: -A representative of the business office would review the resident's records upon notification of a resident's death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's oxygen tubing was stored in a bag and dated when staff had changed out the tubing for two sampled residents, (Resident #8 and Resident #304), and to ensure a resident's Continuous Positive Airway Pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while sleeping) machine had distilled water for the reservoir, and to ensure the resident's CPAP mask was cleaned daily for one sampled resident (Resident #305) and the CPAP mask was stored appropriately in a bag when not in use for one sampled resident (Resident #12) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's Policy Oxygen Therapy for Adults in Long Term Care Setting, dated 8/4/22 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of the four medication carts were locked when the nursing staff was not within direct line of sight of the medication cart. The facility census was 53 residents. Review of the facility's policy, Storage of Medications, dated as retrieved on 2/6/24 showed: -The nursing staff would be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments containing drugs and biologicals (a therapeutic substance, such as a vaccine or drug) should have been locked when not in use. -Carts used to transport such items should not have been left unattended if open or otherwise potentially available to others. 1. Observation on 1/31/24 at 11:25 A.M. with Registered Nurse (RN)/Wound Care Nurse (WCN) showed: -He/She went into a resident's room to do wound care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly screen and follow their policy for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for one sampled resident (Resident #47) out of five residents sampled for TB screening. The facility also failed to implement infection control practices by not following infection control protocols during wound care for one sampled resident (Resident #355); to ensure the Foley catheter (a tube passed into the bladder to drain urine) tubing was not touching the floor and the drainage bag was properly placed in a clean dignity/privacy bag (a bag to place a Foley catheter drainage bag into to keep out of view) for one sampled resident (Resident #30); [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a complete Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level I Screening for one sampled resident (Resident #12) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's Behavior Assessment and Monitoring Policy dated 3/13/23 showed: -The interdisciplinary team will utilize information from the PASRR process as well as complete a comprehensive assessment of the resident needs, strengths, goals, life history and preference using the Resident Assessment Instrument (RAI) process specified by Centers for Medicare and Medicaid Services (CMS). -The Preadmission and PASRR Process: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a pain patch was not left on the resident's breakfast tray for one sampled resident (Resident #105) and to ensure a nursing staff member did not leave medications in the resident's room for the resident to self-administer without a nursing staff member present for one sampled resident (Resident #19) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's policy titled Self-Administration of Medication dated as revised 3/8/21 showed instructions to assess residents to determine if they were capable of self-administering over-the-counter medications. 1. Review of Resident #105's care plan dated 1/24/24 showed the resident experienced pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician ordered special mattress was in place to minimize a Stage III wound (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) for one sampled resident (Resident #2) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's policy, Skin Care - Wound Care), dated 2/6/24 showed: -The Wound Care Team and/or the primary nurses were responsible for providing care for the patient with a skin wound. -Ordered or recommended wound care would have been provided by facility staff while properly following all standards of practice for wound care. -Staff was to have implemented Individualized Plan of Care. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the Pneumococcal Immunization Informed Consent form correctly before having the resident and nurse sign it; and failed to re-offer the immunization for one sampled resident (Resident #8) out of five residents sampled for immunizations. The facility census was 53 residents. Requested a policy for Pneumococcal Immunization and received an updated Consent for Vaccine form. 1. Review of Resident #8's face sheet showed he/she was admitted on [DATE] and re-admitted on [DATE] with the following diagnoses: -Chronic (persisting for a long time or constantly recurring) Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing) with acute (sudden onset) lower respiratory infection. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receiving dialysis (a treatment for kidney failure that removes waste and excess fluids) had physician's orders indicating where and when the resident was to go for dialysis appointments and to ensure ongoing communication between the facility and dialysis centers was maintained to provide continuum of care and to develop individualized comprehensive care plans that included the resident's dialysis goals and interventions for two sampled residents (Resident #21 and Resident #41) out of 12 sampled residents. The facility census was 44 residents. Record review of the facility Caring for a Dialysis Resident policy dated 5/20/21 showed: -The care of the resident receiving dialysis services must reflect ongoing communication, coordination and collaboration between the facility and the dialysis staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store food in the refrigerated walk-in unit and to practice sanitary and hygienic practices before, during and after food preparation tasks. These practices potentially affect an unknown number of residents who received their meals from the facility's kitchen. The facility census was 44 residents. 1. Observations on 7/15/22 between 5:03 A.M. and 7:29 A.M. in the kitchen, showed: -The Executive Chef (EC) walking around the various food preparation tables with a digital thermometer testing and taking food temperatures. -The EC had a surgical, infection control mask covering his/her mouth and nose. -The EC had facial hair protruding out from the sides of his/her surgical mask, resembling that of a beard. -The EC did not have his/her facial hair covered with a hair restraint. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that foods were prepared in accordance with the current Food and Drug Administration (FDA) standards in order to preserve their nutrients. This practice potentially affects all residents and staff who eat foods from the kitchen. The facility census was 44 residents. 1. Observations on 7/15/22 between 5:03 A.M. and 7:29 A.M. in the kitchen, showed: -At 5:45 A.M. the Sousse Chef (SC) placed a tray of pork breakfast sausage links into the oven. -The oven was set at a temperature of 350ºF (degrees Fahrenheit - unit of measurement as a temperature scale). -At 6:10 A.M. the SC removed the tray of pork sausage links from the oven and took the temperatures. -The temperature of the pork sausage links read in excess of 200ºF. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen nasal cannula (is the oxygen delivery tube with two small prongs that fit in the nostrils a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) tubing was stored per facility policy when not in use for one sampled resident (Resident #33) out of 12 sampled residents. The facility census was 44 residents. Record Review of Oxygen Therapy for Adults in Long Term Care Setting policy dated 11/2/19 revised 9/21/21 showed: - All nasal cannulas, oxygen tubing, and nebulizer masks are to be stored in a plastic bag when not being used. -All nasal cannulas and oxygen tubing is to be prevented from dragging or touching the floor by use of a plastic bag to store tubing. 1. [...]