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Deficiency Records for Bishop Drumm Retirement Center

View the most recent health deficiencies and inspection results for Bishop Drumm Retirement Center. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Bishop Drumm Retirement Center. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2026-02-18 2026-04-20 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2026-02-18 2026-04-20 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2026-02-18 2026-04-20 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2026-02-18 2026-04-20 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 2026-02-18 2026-04-20 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2026-02-18 2026-04-20 Y
Ensure that residents are free from significant medication errors. Health 2026-02-18 2026-04-20 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2026-02-18 2026-04-20 Y
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2026-02-18 2026-04-20 Y
Provide and implement an infection prevention and control program. Health 2026-02-18 2026-04-20 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2025-09-17 2025-10-16 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2025-09-17 2025-10-16 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2025-09-17 2025-10-16 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 2025-09-17 2025-10-16 Y
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2025-09-17 2025-10-16 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 2025-09-17 2025-10-16 Y
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2025-09-17 2025-10-16 Y
Provide and implement an infection prevention and control program. Health 2025-09-17 2025-10-16 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-07-21 2025-09-28 N
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 2025-07-21 2025-07-30 N
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Health 2025-07-21 2025-07-30 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-07-21 2025-07-30 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2025-07-21 2025-07-30 N
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 2025-07-21 2025-07-30 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 2025-07-21 2025-07-30 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-07-21 2025-07-30 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 2025-07-21 2025-07-30 Y
Provide and implement an infection prevention and control program. Health 2025-07-21 2025-07-30 Y
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2025-07-21 2025-07-28 N
Install corridor and hallway doors that block smoke. Fire Safety 2025-07-21 2025-07-28 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2025-07-21 2025-07-28 N
Install an approved automatic sprinkler system. Fire Safety 2025-07-21 2025-07-28 N
Have properly located and lighted "Exit" signs. Fire Safety 2025-07-21 2025-07-28 N
Ensure proper usage of power strips and extension cords. Fire Safety 2025-07-21 2025-07-25 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2025-07-21 2025-07-25 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-04-03 2025-06-11 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-04-03 2025-06-11 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-05-29 2025-06-11 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-05-29 2025-06-11 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 2025-04-03 2025-04-22 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2025-04-03 2025-04-22 Y
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2024-09-19 2024-10-11 N
Provide and implement an infection prevention and control program. Health 2024-09-19 2024-10-09 N
Provide enough food/fluids to maintain a resident's health. Health 2024-09-19 2024-10-09 N
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2024-09-19 2024-10-09 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-09-19 2024-10-09 Y
Have proper medical gas storage and administration areas. Fire Safety 2024-09-19 2024-09-25 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-08-18 2024-09-04 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-06-27 2024-09-04 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 2024-06-27 2024-07-24 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2024-06-27 2024-07-24 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-05-03 2024-05-17 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-05-03 2024-05-17 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-05-03 2024-05-17 Y
Provide and implement an infection prevention and control program. Health 2024-02-27 2024-03-20 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-02-27 2024-03-20 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-02-27 2024-03-20 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-02-27 2024-03-20 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-02-27 2024-03-20 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-02-27 2024-03-20 Y
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
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
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 2023-08-08 2023-10-25 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-10-09 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 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 2023-06-29 2023-08-31 N
Provide and implement an infection prevention and control program. Health 2023-06-29 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
Ensure that residents are free from significant medication errors. 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 services provided by the nursing facility meet professional standards of quality. Health 2023-08-08 2023-08-23 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
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-06-29 2023-07-29 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
Provide care and assistance to perform activities of daily living for any resident who is unable. 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
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
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 dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-06-29 2023-07-29 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. 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
Implement a program that monitors antibiotic use. 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
Have proper medical gas storage and administration areas. Fire Safety 2023-06-29 2023-07-14 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-06-29 2023-07-11 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2023-06-29 2023-07-11 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-06-29 2023-07-11 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-06-29 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 2023-06-29 2023-06-29 N

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