Deficiency Records for Bishop Rehabilitation and Nursing Center

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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