Bishop Care Center

In the surveyor’s words

From the most serious findings on record at Bishop Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF725Apr 2, 2025

  Based on interview and record review, the facility failed to provide sufficient numbers of staff when 52 sampled days from October ' 2024 till March ' 2025 had less than 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility). This failure had the potential to result in unmet needs, such as psychosocial, physical needs, and safety concerns for 97 residents. Findings: During an interview with Certified Nurse Assistant 1 (CNA 1) on April 1. 2025, at 3:10 PM. CNA 1 stated we are unable to provide 1:1 care to one of our residents who wander off to other resident ' s room due to not having enough staff. […]

• No harm, potential for more than minimal, widespreadF725Mar 11, 2024

  Based on observation, interviews, and record reviews, the facility failed to provide sufficient numbers of direct care (staff who directly provide nursing services to residents) staff when eleven out of 15 sampled days (for the period of January 23, 2024, to February 07, 2024) had less than 2.4-3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility). This failure had the potential to result in unmet needs, to include assisting residents who requiring feeding or incontinence care to prevent skin breakdown; delay in needed pain medications; prevention of falls or resident to resident altercations; and social isolation by not being able to get to activities of their choice in a… […]

• No harm, potential for more than minimal, widespreadF727May 11, 2023

  Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours for multiple sampled days during the fiscal year Quarter 3 of 2022 (April 2 - June 30). This failure had the potential for all residents living in the facility to not receive services and advanced care activities specifically performed by a registered nurse including resident assessments, administration of intravenous medications, and general oversight of the residents' clinical needs either directly by the RN or indirectly by the Licensed Vocational Nurses or Certified Nursing Assistants for whom the RN was responsible for overseeing resident care. […]

• No harm, potential for more than minimal, widespreadF836May 11, 2023

  Based on interview and record review, the facility failed to ensure it met minimum staffing requirements of 3.5 Direct Care Service Hours Per Patient Day (DHPPD - number of hours of direct care service hours per patient day based upon the facility census [total resident count] and staff working within a 24 hour period) for multiple sampled days during the fiscal year 2022 Quarter 2 (January 1 - March 31), fiscal year 2022 Quarter 3 (April 1 - June 30), and fiscal year 2022 Quarter 4 (July 1 - September 30). This failure had the potential to result in unmet care needs for all residents who resided in the facility. […]

• No harm, potential for more than minimal, patternF604May 21, 2026

  Based on observation, interview, and record review, the facility failed to ensure two out of three sampled residents (Resident 11 and 80) to be free from physical restraints when: 1. For Resident 11, the resident was unable to freely access an exit the bed from both sides as intended, and documentation supporting the need, safety or authorization of the intervention was not provided 2. For Resident 80, the resident's bed was positioned directly against the wall, thereby limiting Resident 80 ability to move freely and restricting safe access. These failures had the potential to contribute to Resident 11 and 80 decline in physical functioning, and increasing the risk of accidents. Findings: 1. […]