Bishop Spencer Place, Inc, The

In the surveyor’s words

From the most serious findings on record at Bishop Spencer Place, Inc, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jul 29, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF684Jun 4, 2021

  Based on interview and record review, the facility failed to notify the resident's physician of a change of condition, failed to notify the physician or respond to a resident's elevated blood glucose, and failed to continue to assess or monitor the resident's elevated blood glucose for one sampled resident (Resident #1). During shift change at 7:00 A.M., the resident was found clammy, lethargic, with a blood glucose (the amount of sugar in the blood) of 577 (milligrams per deciliter-mg/dl). A repeat blood glucose was 571 mg/dl. The resident continued to have a change in mental status and was discharged to home at 3:05 P.M. […]

• No harm, potential for more than minimal, widespreadF880Jan 9, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF881Jan 9, 2026

  Based 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. Review of the facility's policy titled Antimicrobial Stewardship in Senior Living Communities, GA-457 dated 9/23/25 showed:-The facility would establish and maintain as Antimicrobial Stewardship Program (ASP) to ensure optimal use of antimicrobials in the treatment and prevention of infectious diseases.-The ASP would focus its efforts on reviewing appropriateness of antimicrobial regimens for residents within the facility.-All residents with antimicrobials would be… […]

• No harm, potential for more than minimal, widespreadF812Feb 6, 2024

  Based 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. […]