Deficiency Records for Bishop Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Bishop Rehabilitation and Nursing 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 | 2023-12-05 | 2024-02-02 | Y |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-12-05 | 2024-02-02 | Y |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-12-05 | 2024-02-02 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-05 | 2024-02-02 | Y |
Provide a written emergency evacuation plan. | Fire Safety | 2023-10-13 | 2023-11-22 | Y |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-24 | 2023-08-10 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-28 | 2023-07-24 | Y |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-24 | 2023-07-19 | N |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-24 | 2023-07-19 | N |
Respond appropriately to all alleged violations. | Health | 2023-05-24 | 2023-07-19 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-24 | 2023-07-19 | N |
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. | Health | 2023-05-24 | 2023-07-19 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-24 | 2023-07-19 | N |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-24 | 2023-07-19 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-24 | 2023-07-19 | 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 | 2023-05-24 | 2023-07-19 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-24 | 2023-07-19 | Y |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-05-24 | 2023-07-19 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-24 | 2023-07-19 | Y |
Provide activities to meet all resident's needs. | Health | 2023-05-24 | 2023-07-19 | 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 | 2023-05-24 | 2023-07-19 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-24 | 2023-07-19 | Y |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-24 | 2023-07-19 | Y |
Ensure that residents are free from significant medication errors. | Health | 2023-05-24 | 2023-07-19 | Y |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-24 | 2023-07-19 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-05-24 | 2023-07-19 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-24 | 2023-07-19 | Y |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-05-24 | 2023-07-18 | 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 | 2023-05-24 | 2023-07-18 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-05 | 2023-03-31 | Y |
Respond appropriately to all alleged violations. | Health | 2023-03-05 | 2023-03-27 | Y |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-05 | 2023-03-27 | 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 | 2023-01-19 | 2023-02-07 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-19 | 2023-02-07 | Y |
Respond appropriately to all alleged violations. | Health | 2023-01-19 | 2023-02-07 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-19 | 2023-02-07 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-02-07 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-19 | 2023-02-07 | Y |
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-11-02 | 2023-01-19 | N |
Provide and implement an infection prevention and control program. | Health | 2022-11-02 | 2023-01-19 | N |
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. | Health | 2022-11-02 | 2023-01-19 | 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 | 2022-11-02 | 2022-12-17 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-02 | 2022-12-17 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-02 | 2022-12-17 | N |
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 | 2022-11-02 | 2022-12-17 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-02 | 2022-12-17 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-02 | 2022-12-17 | N |
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-11-02 | 2022-12-17 | N |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-11-02 | 2022-12-17 | N |
Keep all essential equipment working safely. | Health | 2022-11-02 | 2022-12-17 | N |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-11-02 | 2022-12-17 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-02 | 2022-12-17 | Y |
Respond appropriately to all alleged violations. | Health | 2022-11-02 | 2022-12-17 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-02 | 2022-12-17 | Y |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-11-02 | 2022-12-17 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-02 | 2022-12-17 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-02 | 2022-12-17 | Y |
Install a two-hour-resistant firewall separation. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-11-02 | 2022-12-17 | 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 | 2022-11-02 | 2022-12-17 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-02 | 2022-12-17 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-07 | 2022-10-10 | Y |
Respond appropriately to all alleged violations. | Health | 2022-09-07 | 2022-10-10 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-07 | 2022-10-10 | Y |
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 | 2022-09-07 | 2022-10-10 | Y |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-07 | 2022-10-10 | Y |
Ensure that residents are free from significant medication errors. | Health | 2022-09-07 | 2022-09-27 | Y |
Install an approved automatic sprinkler system. | Fire Safety | 2022-05-05 | 2022-07-07 | N |
Implement emergency and standby power systems. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-05-05 | 2022-06-22 | 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 | 2022-05-05 | 2022-06-22 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-05 | 2022-06-22 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-04 | 2022-06-15 | N |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-05-04 | 2022-06-15 | N |
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. | Health | 2022-05-04 | 2022-06-15 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-04 | 2022-06-15 | N |
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-05-04 | 2022-06-15 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-04 | 2022-06-15 | 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 | 2022-05-04 | 2022-06-15 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-04 | 2022-06-15 | 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 | 2022-05-04 | 2022-06-15 | Y |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-04 | 2022-06-15 | 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 | 2022-05-04 | 2022-06-15 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-04 | 2022-06-15 | Y |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-04 | 2022-06-15 | Y |
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-05-04 | 2022-06-15 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-05-04 | 2022-06-15 | Y |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-04 | 2022-06-15 | Y |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-05-04 | 2022-06-15 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-05-04 | 2022-06-15 | Y |
Keep all essential equipment working safely. | Health | 2021-12-15 | 2022-01-31 | Y |
Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-10-25 | 2021-11-18 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-23 | 2021-11-10 | 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 | 2021-09-20 | 2021-11-10 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-20 | 2021-11-10 | Y |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-20 | 2021-11-10 | Y |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-09-20 | 2021-11-10 | Y |
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-09-03 | 2021-10-26 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-13 | 2021-09-23 | Y |
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-06-30 | 2021-08-17 | Y |