Cycle 1
Health 2025-03-06 · Fire 2025-03-06
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Escanaba, MI
Bishop Noa Home for Senior Citizens
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2900 Third Avenue South, Escanaba, MI
(906) 786-5810
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
81
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.01
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.15
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.85
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.21
CMS adjusted RN staffing hours
Adjusted total hours
5.79
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
976
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.45
Composite VBP score used to determine payment impact.
Payment multiplier
1.0165
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.22
Performance 20.40% · Measure score 2.22 · Achievement 2.22 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.54
Performance 6.18% · Measure score 5.54 · Achievement 5.54 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
8.34
Baseline 54.41% · Performance 29.58% · Measure score 8.34 · Achievement 8.34 · Improvement 7.90
Adjusted total nurse staffing
8.48
Baseline 4.96 hours · Performance 5.49 hours · Measure score 8.48 · Achievement 8.48 · Improvement 5.98
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.79% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 5.45% · Lower 95% interval 6.19% |
| Discharge to community | 39.42% |
50.57%
11.1 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 31.11% · Lower 95% interval 29.01% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 29 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | 32% |
53.69%
21.7 pts worse
|
Numerator 8 · Denominator 25 |
| Discharge mobility score | 36% |
50.94%
14.9 pts worse
|
Numerator 9 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 6.9% |
2.29%
4.6 pts worse
|
Numerator 2 · Denominator 29 · Adjusted rate 7.91% |
| Healthcare-associated infections requiring hospitalization | 6.18% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 0% · Lower 95% interval 2.65% |
| Staff COVID-19 vaccination coverage | 17.12% |
8.2%
8.9 pts better
|
Numerator 25 · Denominator 146 |
| Staff flu vaccination coverage | 44.17% |
42%
2.2 pts better
|
Numerator 72 · Denominator 163 |
| Discharge function score | 32% |
56.45%
24.5 pts worse
|
Numerator 8 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
1.5
2.5 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 4.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.1%
1.5 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 1.8% · Q4 1.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
4.1%
2.4 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 3.6% · Q4 1.6% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
5.5%
4 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.5% · Q3 14.3% · Q4 5.0% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
19.6%
11.6 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 10.0% · Q3 4.0% · Q4 3.3% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
16.5%
5.3 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 10.2% · Q3 8.7% · Q4 12.5% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.1%
0.7 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 1.5% · 4Q avg 0.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.1% |
13.9%
6.2 pts worse
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 14.7% · Q3 32.8% · Q4 17.3% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
11.7%
2 pts worse
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 16.4% · Q3 12.8% · Q4 8.5% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.9%
0.7 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 3.6% · Q4 1.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.7%
0.3 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.5% · Q3 1.8% · Q4 1.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
20.4%
6.8 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 34.1% · Q3 31.9% · Q4 27.2% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.6%
1.4 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.5% · Q3 5.8% · Q4 6.2% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
82.8%
14.9 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 100.0% · Q3 100.0% · Q4 94.1% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
11.5%
9.7 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 20.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
79.5%
8.5 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 8.1% |
24.2%
16.1 pts better
|
23.9%
15.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 8.0% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-20 · Fire 2024-03-20
7 health deficiencies
Top issue: Administration (2 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2023-05-04 · Fire 2023-05-04
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-02
F · Potential for more than minimal harm
2025-03-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-02
F · Potential for more than minimal harm
2025-03-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-04-02
F · Potential for more than minimal harm
2024-03-20
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-03-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-03-20
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-04-17
F · Potential for more than minimal harm
2023-05-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-05-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-05-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-05-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-05-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-05-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-05-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-05-04
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-05-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-06
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-06
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-04
D · Potential for more than minimal harm
2024-12-18
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-03-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-19
F · Potential for more than minimal harm
2024-03-20
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-04-19
F · Potential for more than minimal harm
2024-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-20
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-04-19
E · Potential for more than minimal harm
2023-12-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-05-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-15
Penalties and ownership
What sits behind the stars
Ownership
Sisters Of St. Paul De Chartres
5% Or Greater Direct Ownership Interest · Organization
Beckon, Susan
Corporate Officer · Individual
Berbohm, Karen
Corporate Officer · Individual
Ferguson, Timothy
Corporate Officer · Individual
Lafave, Jamie
Operational/Managerial Control · Individual
Lafave, Jamie
Corporate Officer · Individual
Laurin, Mary Ann
Corporate Officer · Individual
Linder, Nicole
Operational/Managerial Control · Individual
Schultz, Gloria
Corporate Officer · Individual
Theoret, Raymond
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Christian Park Village
Escanaba, MI
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Christian Park Health Care Center
Escanaba, MI
3-star overall rating with 3-star inspections with $36,651 in total fines with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Pinecrest Medical Care Facility
Powers, MI
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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