A list of the most recent deficiencies for Bishop Drumm Retirement Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-10 | 2024-01-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-09 | 2023-10-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-09 | 2023-10-25 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-09 | 2023-10-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-08 | 2023-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-10-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-06-29 | 2023-10-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-09 | 2023-10-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-09 | 2023-10-09 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-28 | 2023-08-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-08 | 2023-08-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-08 | 2023-08-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-08 | 2023-08-23 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-06-29 | 2023-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-08-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-29 | 2023-07-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-29 | 2023-07-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-06-29 | 2023-07-29 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-06-29 | 2023-07-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-29 | 2023-07-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-29 | 2023-07-29 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-29 | 2023-07-29 | Y |
| 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. | Health | 2023-06-29 | 2023-07-29 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-29 | 2023-07-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-29 | 2023-07-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-29 | 2023-07-29 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-06-29 | 2023-07-29 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-29 | 2023-07-29 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-28 | 2023-07-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-28 | 2023-07-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-28 | 2023-07-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-28 | 2023-07-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-06-28 | 2023-07-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-28 | 2023-06-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-18 | 2022-09-20 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-08-18 | 2022-09-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-19 | 2022-06-18 | Y |
| 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. | Health | 2022-05-19 | 2022-06-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-19 | 2022-06-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-19 | 2022-06-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-19 | 2022-06-18 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-19 | 2022-06-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-19 | 2022-06-18 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-11 | 2022-06-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-05-11 | 2022-06-03 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-05-11 | 2022-06-03 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-05-11 | 2022-05-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-11 | 2022-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-11 | 2022-05-20 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-05-11 | 2022-05-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-11 | 2022-05-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-11 | 2022-05-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-11 | 2022-05-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-02-24 | 2021-04-03 | N |
| 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. | Health | 2021-02-24 | 2021-04-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-02-24 | 2021-04-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-02-24 | 2021-04-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-02-24 | 2021-04-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-24 | 2021-04-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-24 | 2021-04-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-02-24 | 2021-04-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-02-24 | 2021-04-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-02-24 | 2021-04-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-02-24 | 2021-04-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-24 | 2021-04-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-24 | 2021-04-03 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-02-24 | 2021-04-03 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-02-24 | 2021-04-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-02-16 | 2021-02-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-02-16 | 2021-02-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-02-16 | 2021-02-23 | N |
