Inspection Reports for Bishop Drumm Retirement Center
5837 Winwood Drive, IA, 501311651
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 13, 2025
Visit Reason
A revisit of the survey ending September 17, 2025 was conducted from November 10, 2025 to November 13, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective October 16, 2025.
Report Facts
Dates of previous survey and revisit: Previous survey ended September 17, 2025; revisit conducted November 10-13, 2025; substantial compliance effective October 16, 2025
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 13, 2025
Visit Reason
A complaint investigation for complaints #2657671-C and #2665339-C was conducted from November 12, 2025 to November 13, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to complaints #2657671-C and #2665339-C; the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 29, 2025
Visit Reason
A complaint investigation for facility reported incidents #Incident 2636485 was conducted from October 27, 2025 to October 29, 2025.
Findings
The facility was not cited with concerns related to this complaint investigation; however, the facility is not in compliance due to previous visits ending July 21, 2025, and September 17, 2025.
Complaint Details
Complaint investigation for incident #2636485 was conducted and no concerns were cited related to this investigation.
Report Facts
Incident number: 2636485
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 8
Sep 17, 2025
Visit Reason
The inspection was conducted as a revisit following investigation of complaints #2577057-C, #2580711-C, #2612229-C, and #2612253-C, focusing on notification of changes, services meeting professional standards, treatment to prevent pressure ulcers, bowel/bladder incontinence care, tube feeding management, sufficient nursing staff, infection prevention and control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to notify family/emergency contacts of significant resident changes, inadequate weight monitoring and documentation, insufficient care and treatment for pressure ulcers, inadequate catheter care, failure to flush enteral feeding tubes properly, insufficient nursing staff response to call lights, and lapses in infection control practices. The facility had repeated deficiencies from prior surveys and was working on corrective actions.
Complaint Details
The visit was a revisit following investigation of complaints #2577057-C, #2580711-C, #2612229-C, and #2612253-C, which resulted in deficiencies.
Severity Breakdown
Level D: 6
Level F: 1
Level G: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to notify resident family/emergency contacts of significant change in condition. | Level D |
| Failure to provide care and services according to accepted clinical standards, including inadequate weight monitoring for residents with feeding tubes. | Level D |
| Failure to identify and treat pressure ulcers appropriately. | Level G |
| Failure to provide appropriate care for bladder and bowel incontinence and catheter care. | Level D |
| Failure to properly manage tube feeding including flushing enteral feeding tubes. | Level D |
| Insufficient nursing staff to answer call lights timely. | Level D |
| Failure to maintain infection prevention and control practices including hand hygiene and use of enhanced barrier precautions. | Level D |
| Failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program. | Level F |
Report Facts
Census: 114
Weight loss: 8.8
Weight loss: 11.9
Weight loss: 21.4
Pressure ulcer size: 2.5
Pressure ulcer size: 3
Pressure ulcer size: 4
BIMS score: 12
BIMS score: 13
BIMS score: 14
BIMS score: 15
Urinalysis bacteria count: 100000
Call light response time: 40
Call light response time standard: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Verified family notification was not documented; expected staff to follow physician orders; reported facility skin protocol and call light response expectations. |
| Staff A | Registered Nurse | Observed performing wound treatments and tube feeding procedures. |
| Nurse Practitioner | Nurse Practitioner (NP) | Evaluated Resident #10's left heel pressure ulcer and provided assessment. |
| Administrator in training | Infection Preventionist | Reported expectations for obtaining weights according to physician orders. |
| Staff Development Coordinator | Staff Development Coordinator | Provided education to licensed nursing staff regarding policies and processes. |
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 9
Jul 21, 2025
Visit Reason
Annual Recertification Survey and investigation of Complaints #1724515-C, #2564085-C, and Facility Reported Incident #1724511-I conducted from July 14, 2025 to July 21, 2025.
Findings
The facility was found deficient in multiple areas including documentation of accurate code status, providing a safe and homelike environment, notification to the Long Term Care Ombudsman upon resident discharge, development and implementation of comprehensive care plans, conducting care conferences with legal guardians, reporting changes in resident condition and skin assessments, carrying out therapy recommendations and restorative exercises, timely answering call lights, and infection prevention and control practices.
Complaint Details
The inspection included investigation of Complaints #1724515-C, #2564085-C, and Facility Reported Incident #1724511-I. Deficiencies were cited for all complaints and the facility reported incident.
Severity Breakdown
SS = D: 8
SS = G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to document an accurate code status for one resident (Resident #11). | SS = D |
| Failed to provide a safe, clean, comfortable and homelike environment, including maintenance issues with doors, windowsills, call lights, and electrical outlets. | SS = D |
| Failed to provide notification to the Long Term Care Ombudsman for resident discharges (Resident #1). | SS = D |
| Failed to develop and implement a comprehensive person-centered care plan for residents (Residents #100 and #62). | SS = D |
| Failed to conduct resident care conferences and offer legal guardian participation for Resident #3. | SS = D |
| Failed to report a resident’s change in condition and failed to assess and document skin assessments for Resident #5. | SS = D |
| Failed to carry out therapy recommendations and provide restorative exercises for Resident #10. | SS = G |
| Failed to answer call lights in a timely manner (15 minutes or less) for 3 of 4 units. | SS = D |
| Failed to follow infection control practices for a resident with a feeding tube (Resident #79) and a resident with a catheter (Resident #19). | SS = D |
Report Facts
Resident census: 107
Deficiency count: 9
Call light response time: 15
Care plan review frequency: 5
Care conferences review frequency: 10
Skin assessment review frequency: 5
Restorative care review frequency: 5
Infection control observation frequency: 10
Catheter observation frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Named in infection control observation and medication administration for Resident #79 |
| Staff B | Certified Nursing Assistant | Named in infection control observation and resident transfer for Resident #79 |
| Staff C | Certified Nursing Assistant | Named in infection control observation and resident transfer for Resident #79 |
| Staff D | Certified Medication Aide | Named in code status and restorative care findings |
| Staff F | Registered Nurse | Named in code status and skin assessment findings |
| Staff G | Registered Nurse | Named in skin assessment and wound care findings |
| Staff H | Occupational Therapist | Named in therapy and restorative care findings for Resident #10 |
| Staff I | Registered Nurse | Named in skin assessment and wound care findings |
| Staff J | Certified Medication Aide | Named in skin assessment and wound care findings |
| Staff L | Restorative Nursing Assistant | Named in restorative care findings |
| Staff M | Restorative Nursing Assistant | Named in restorative care findings |
| Staff E | Licensed Social Worker | Named in discharge notification and care conference findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including code status, infection control, care plans, and staffing |
| Administrator | Administrator | Named in environment and discharge notification findings |
| Maintenance Director | Maintenance Director | Named in environment and maintenance findings |
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 1, 2025
Visit Reason
A second revisit of the survey ending April 3, 2025 was conducted on June 30, 2025 to July 1, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective June 11, 2025.
Report Facts
Dates of survey and revisit: Survey ending April 3, 2025; revisit June 30, 2025 to July 1, 2025; substantial compliance effective June 11, 2025
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 2
May 29, 2025
Visit Reason
The inspection was a revisit of the survey ending 2025-04-03 and investigation of multiple complaints (#127744-C, #128137-C, #128400-C, #128437-C, #128434-C, and #128934-C) conducted from 2025-05-22 through 2025-05-29.
Findings
The facility failed to promptly notify a medical provider of a resident's change in condition related to hyperglycemia and sepsis, resulting in hospitalization. Additionally, inadequate supervision and failure to follow the care plan led to a resident's fall causing injury. The facility's care plans and staff responses were found deficient in both cases.
Complaint Details
The visit was complaint-related involving Complaints #127744-C, #128137-C, #128400-C, #128437-C, #128434-C, and #128934-C. Complaints #128137-C, #128437-C, #128834-C, and #128834-C resulted in deficiencies.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to promptly notify a medical provider of a resident's change in condition related to hyperglycemia and sepsis. | SS=D |
| Failure to provide adequate supervision and follow the care plan for a resident, resulting in a fall and injury. | SS=D |
Report Facts
Resident census: 117
Blood sugar readings: 437
Blood sugar readings: 695
Skin tear size: 5
Skin tear size: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Documented Resident #3 fall and assessed injury |
| Staff C | Registered Nurse (RN) | Provided shift report and described Resident #2's condition and actions taken |
| Director of Nursing | Director of Nursing (DON) | Provided statements on facility expectations and corrective actions |
| Medical Director | Medical Director | Provided statements regarding Resident #2's care and provider communication |
| Staff A | Registered Nurse (RN) | Witnessed Resident #3 fall and provided wound care |
| Staff D | Certified Nurse Aide (CNA) | Assigned to care for Resident #3 on day of fall but denied knowledge of fall |
| Staff E | Certified Nurse Aide (CNA) | Assigned to care for Resident #3 after 3:00 pm on day of fall but was not on duty |
| Staff G | Restorative Aide | Described Resident #3's behavior and care needs |
| F | Certified Nurse Aide (CNA) | Described Resident #3's mobility and assistance needs |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 4
Apr 3, 2025
Visit Reason
Investigation of multiple complaints and facility reported incidents conducted from April 1, 2025 to April 3, 2025, including substantiated complaints and incidents related to quality of care, accident hazards, nursing staff sufficiency, and pest control.
Findings
The facility failed to perform post dialysis assessments and post fall assessments timely, failed to ensure adequate supervision and proper use of mechanical lifts during resident transfers, failed to respond to call lights in a timely manner, and failed to maintain an effective pest control program with evidence of mice in resident rooms.
Complaint Details
Complaints #126896-C, #127397-C, #127484-C, #127629-C, #127672-C, #127693-C and Facility Reported Incident #127549-I were investigated. Complaints #126896-C, #127397-C, #127484-C, #127629-C, and #127672-C were substantiated. Facility reported incident #127549-I was substantiated.
Severity Breakdown
SS=G: 2
SS=E: 1
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to perform post dialysis assessment and assess for side effects of missed medication doses for Resident #2; failed to document post fall assessment for Resident #9. | SS=G |
| Failed to ensure adequate supervision and assistance devices to prevent accidents for residents requiring mechanical equipment device transfers (Residents #3 and #7). | SS=G |
| Failed to provide sufficient nursing staff to assure resident safety by not responding to call lights in a timely manner for 4 of 6 residents reviewed (Residents #5, #6, #7, and #11). | SS=E |
| Failed to maintain an effective pest control program; residents reported mice in rooms and evidence of mice droppings and gaps in building structure allowing pest entry. | SS=D |
Report Facts
Residents reviewed for assessment and intervention: 3
Residents reviewed for falls: 3
Census: 119
Number of residents with call light response issues: 4
Number of residents reviewed for nursing staff sufficiency: 6
Number of residents reviewed for accident hazards: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Licensed Practical Nurse (LPN) | Named in failure to perform post dialysis assessment and medication administration on 3/22/25 |
| Staff H | Infection Prevention Nurse | Present during Resident #9 fall and assisted with assessment |
| Staff J | Registered Nurse (RN) | Charge nurse during Resident #9 fall; responsible for documentation |
| Staff E | Certified Nursing Assistant (CNA) | Involved in improper transfer of Resident #3 using incorrect mechanical lift |
| Staff F | Director of Maintenance and Facilities | Reported pest control issues and maintenance actions |
| Staff B | President of Pest and Termite Control Services | Pest control service representative interviewed regarding mice concerns |
| Staff A | Certified Nursing Assistant (CNA) | Observed transferring Resident #7 without proper gait belt use |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding nursing expectations, deficiencies, and corrective actions |
| Administrator | Facility Administrator | Interviewed regarding call light response expectations and pest control |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 11, 2025
Visit Reason
A complaint investigation was conducted for Complaints #126268-C, #125896-C, #125081-C and Facility Reported Incident #125672-I from February 11, 2025 to February 13, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation involved multiple complaints and a facility reported incident; the facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 30, 2024
Visit Reason
A revisit of the survey ending September 19, 2024 and investigation of Complaints #123761-C, #124024-C, #124073-C, #124251-C, and Facility Reported Incidents #123679-I, and #123951-I was conducted October 28, 2024 to October 30, 2024.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective October 9, 2024.
Complaint Details
Investigation of Complaints #123761-C, #124024-C, #124073-C, #124251-C was conducted and deficiencies were corrected.
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 5
Sep 19, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and included investigation of Complaints #123184-C and Facility Reported Incidents #123367-I.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to maintain acceptable nutritional status for a resident resulting in significant weight loss, failure to secure resident electronic health records, and failure to implement proper infection prevention and control practices. Additionally, the facility failed to timely assess Veterans Affairs status for new residents.
Complaint Details
The inspection included investigation of Complaints #123184-C and Facility Reported Incidents #123367-I.
Severity Breakdown
SS=E: 3
SS=G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Staff argued in front of residents, failing to treat residents with dignity. | SS=E |
| Failure to maintain acceptable nutritional status for Resident #69, resulting in a 10.4% weight loss over 3 months. | SS=G |
| Failure to secure Electronic Health Record information for 16 residents. | SS=E |
| Failure to implement infection control practices, including improper catheter bag placement, failure to use PPE and hand hygiene, and improper medication administration practices. | SS=E |
| Failure to ensure timely assessment of Veterans Affairs status for 21 of 25 residents reviewed. | — |
Report Facts
Residents present during inspection: 120
Weight loss percentage: 10.4
Residents not assessed for VA status: 21
Residents reviewed for VA status: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Dietary Attendant | Involved in argument in front of residents |
| Staff I | Culinary Support | Involved in argument in front of residents |
| Director of Dietary | Stated staff should never argue in dining room | |
| Staff K | Licensed Practical Nurse (LPN) | Observed not closing charting monitor and involved in medication administration |
| Staff L | Certified Nurse Aide (CNA) | Accessed charting monitor and involved in medication administration |
| Director of Nursing (DON) | Director of Nursing | Reassessed nutritional status, provided education, and commented on infection control practices |
| Registered Dietitian (RD) | Registered Dietitian | Reassessed nutritional status and provided dietary input |
| Staff M | Certified Nurse Aide (CNA) | Provided feeding assistance to Resident #69 |
| Dietary Supervisor | Provided information on Resident #69's food preferences | |
| Staff D | Certified Nurse Aide (CNA) | Improper catheter bag placement |
| Staff E | Certified Nurse Aide (CNA) | Improper catheter bag placement and PPE use |
| Staff F | Certified Medicine Aide (CMA) | Failed to use PPE and hand hygiene when entering isolation room |
| Staff G | Registered Nurse (RN) | Provided information on isolation precautions |
| Staff A | Certified Nursing Assistant (CNA) | Failed to change gloves and perform hand hygiene appropriately during catheter care |
| Staff J | Certified Medication Aide (CMA) | Failed to perform hand hygiene during medication administration |
| Staff K | Licensed Practical Nurse (LPN) | Failed to perform hand hygiene and gowning during medication administration |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 11, 2024
Visit Reason
A second revisit of the complaint survey ending June 27, 2024 and investigation of complaints #122063-C, #122323-C, and 122560-C was conducted on September 11, 2024.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 4, 2024. DPNA was effectuated from July 24, 2024 to September 3, 2024.
Complaint Details
Investigation of complaints #122063-C, #122323-C, and 122560-C; all deficiencies corrected and facility found in substantial compliance.
Report Facts
Complaint survey end date: Jun 27, 2024
DPNA effective period start: Jul 24, 2024
DPNA effective period end: Sep 3, 2024
Inspection Report
Follow-Up
Census: 119
Deficiencies: 1
Aug 18, 2024
Visit Reason
This inspection was a revisit of the Complaint Survey ending June 27, 2024, and investigation of Complaints #122063-C, 122323-C, and 122560-C conducted August 15-18, 2024.
Findings
The facility failed to prevent the development of a pressure ulcer for one resident, resulting in immediate jeopardy. The resident had a Stage IV pressure ulcer and developed a second Stage IV ulcer requiring hospital treatment. The facility implemented corrective actions including policy revisions, staff education, audits, and ongoing monitoring.
Complaint Details
Complaint #122063-C was substantiated.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent development of pressure ulcer for one resident with Stage IV pressure ulcer, resulting in immediate jeopardy. | Immediate Jeopardy |
Report Facts
Census: 119
Complaint numbers investigated: 3
Audit frequency: 5
Resident audits per week: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing or designee | Provided education to licensed nurses and nurse aides on pressure injury prevention and management | |
| Administrator | Conducted call with Telligen and interdisciplinary team review on 09/04/2024 | |
| Staff B, Registered Nurse | Acting as in-house wound nurse, unfamiliar with resident's wound prior to hospitalization | |
| Staff C, Licensed Practical Nurse | Worked with resident over 6 months, described wound care and repositioning | |
| Staff D, Certified Nursing Assistant | Reported resident occasionally refuses repositioning | |
| Staff E, Certified Nursing Assistant | Reported resident tells her she is ok for now when offered repositioning | |
| Staff F, Certified Medication Aide | Reported resident is to be turned side to side only and never refused repositioning | |
| Wound Advanced Registered Nurse Practitioner (ARNP) | Ordered wound care treatments and evaluated resident's wounds | |
| Staff A, Registered Nurse | Discontinued wound treatment order on 6/17/24 | |
| Director of Nursing (DON) | Monitors wound care and stated CNAs only chart turning in Point of Care |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 3
Jun 27, 2024
Visit Reason
The inspection was conducted as a result of investigation of complaints #120667-C, #120746-C, #121577-C, and #121674-C between June 20, 2024 and June 27, 2024. Complaints #120746-C, #121577-C, and #121674-C were substantiated while complaint #120667-C was unsubstantiated.
Findings
The facility failed to provide adequate care to prevent pressure ulcers for 2 of 6 residents sampled, including Resident #1 and Resident #2, who developed pressure ulcers and skin breakdowns. The facility also failed to provide sufficient nursing staff to meet residents' needs, including timely response to call lights and assistance with repositioning and feeding. The facility has initiated corrective actions including staff education, audits, and a Quality Assurance and Performance Improvement (QAPI) process.
Complaint Details
Complaints #120667-C was unsubstantiated. Complaints #120746-C, #121577-C, and #121674-C were substantiated based on record review, staff interviews, and policy review.
Severity Breakdown
G: 1
F: 1
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to provide care, interventions, and services to prevent the development of pressure sores for 2 of 6 residents sampled. | G |
| Facility failed to have sufficient nursing staff with appropriate competencies and skills to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being. | F |
| Facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. | E |
Report Facts
Census: 116
Residents sampled: 6
New skin tear size: 1.9
New skin areas: 2
Pressure ulcer measurements: 5.7
Pressure ulcer measurements: 6.7
Pressure ulcer measurements: 3.9
Pressure ulcer measurements: 3.6
Staffing units: 3
Call light response times: 24
Staffing levels: 2
Staffing levels: 1
Staffing ratios: 1.15
Residents requiring assistance: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Reported use of app for wound tracking and wound measurement |
| Staff E | Certified Nursing Assistant (CNA) | Reported resident care activities and documentation in Plan of Care |
| Staff F | Certified Nursing Assistant (CNA) | Reported issues with electronic Plan of Care reliability and resident repositioning |
| Staff C | Licensed Practical Nurse (LPN) | Reported skin assessments, wound care follow-up, and staffing concerns |
| Staff G | Registered Nurse (RN) | Reported staffing shortages and care challenges |
| Staff H | Registered Nurse (RN) | Reported skin assessments and staffing shortages |
| Staff J | Registered Nurse (RN) | Reported nursing recommendations and staffing issues |
| Staff B | Licensed Practical Nurse (LPN) | Reported staffing shortages and resident care issues |
| Staff I | Certified Nursing Assistant (CNA) | Reported staffing levels and resident care challenges |
| Director of Nursing | Director of Nursing (DON) | Notified about wounds, ordered equipment, and reported staffing challenges |
| Administrator | Administrator | Responded to surveyor questions about corrective actions and staffing |
| HR Director | Human Resource Director | Reported staffing schedules and hiring activities |
Inspection Report
Plan of Correction
Deficiencies: 0
May 17, 2024
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, resulting in certification of compliance effective May 17, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, leading to certification of compliance.
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 3
May 3, 2024
Visit Reason
The inspection was conducted as a result of investigations into complaints #120338-C, #120391-C, #120403-C, and #120434-C between April 25, 2024 and May 3, 2024. The complaints were substantiated.
Findings
The facility failed to ensure the dignity and respect of residents, specifically Resident #3, who was found sitting in common areas with exposed adult briefs and no pants, contrary to the facility's dignity policy. Additionally, the facility failed to initiate physician orders for Residents #1 and #2 and failed to administer medications as ordered. The facility also failed to provide adequate assistance with activities of daily living for Resident #3. Corrective actions and monitoring plans were implemented.
Complaint Details
Investigation of Complaints #120338-C, #120391-C, #120403-C, and #120434-C was conducted from April 25, 2024 to May 3, 2024. Complaints #120403-C and #120434-C were substantiated.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure dignity of Resident #3, who was observed with exposed adult briefs in common areas. | SS=D |
| Failure to meet professional standards of care related to medication administration and physician orders for Residents #1 and #2. | SS=D |
| Failure to provide adequate assistance with activities of daily living for Resident #3. | SS=D |
Report Facts
Census: 110
BIMS score: 12
BIMS score: 3
Corrective Action Completion Date: May 17, 2024
Observations: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Completed review of Resident #3 and provider recommendations for Resident #1 |
| Staff A Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Reported on Resident #3's dressing and behavior |
| Staff B CNA | Certified Nursing Assistant (CNA) | Reported on Resident #3's dressing and care |
| Staff C | Wound Nurse | Acknowledged failure to initiate vitamin C order for Resident #1 |
| Staff D | Certified Medication Aide (CMA) | Signed medication list for Resident #2 |
| Administrator | Administrator | Reviewed audits and corrective action plans |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Apr 18, 2024
Visit Reason
A revisit of the Complaints survey #118595-C and #118876-C ending February 27, 2024 and investigation of Facility Reported Incident #119791-I was conducted from April 16 to April 18, 2024.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 20, 2024. The facility reported incident #119791-I was not substantiated.
Complaint Details
Facility reported incidents #119791-I was not substantiated.
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 6
Feb 27, 2024
Visit Reason
Investigation of complaints #118595-C, #118737-C, #118876-C and facility reported incidents #117942-I, #118234-I, and #118551-I conducted from February 15, 2024 to February 27, 2024.
Findings
The facility was found deficient in developing and implementing comprehensive care plans, providing services that meet professional standards, preventing and treating pressure ulcers, ensuring adequate supervision to prevent elopement, maintaining complete resident records, and following infection prevention and control practices.
Complaint Details
Complaints #118595-C and #118876-C were substantiated.
Severity Breakdown
SS=D: 5
SS=J: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to implement a comprehensive care plan for Resident #5 related to elopement and wandering behaviors. | SS=D |
| Failed to ensure residents receive treatment and care in accordance with professional standards, including medication administration and treatment documentation for Residents #4 and #11. | SS=D |
| Failed to provide skin assessments per policy and treatments per physician's orders to prevent development and worsening of a Stage IV pressure ulcer for Resident #11. | SS=J |
| Failed to ensure Resident #5 was assessed for elopement risk after leaving the building on 2/13/24. | SS=D |
| Failed to maintain complete and accurate resident records, including bath records for Residents #6, #7, #8 and skin assessments for Resident #11. | SS=D |
| Failed to follow infection control practices during incontinent care for Resident #14, including improper glove use and hand hygiene. | SS=D |
Report Facts
Deficiencies cited: 6
Resident census: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Named in infection control deficiency related to incontinent care. |
| Staff N | Certified Nursing Assistant (CNA) | Named in infection control deficiency related to incontinent care. |
| Staff B | Licensed Practical Nurse (LPN) | Named in infection control deficiency and elopement incident. |
| Staff A | Registered Nurse (RN) | Named in care plan and elopement findings. |
| Staff C | Licensed Practical Nurse (LPN) | Named in care plan and elopement findings. |
| Staff G | Unit Manager | Named in elopement incident. |
| Staff M | Certified Nursing Assistant (CNA) | Named in pressure ulcer care deficiency. |
| Staff J | Certified Nursing Assistant (CNA) | Named in pressure ulcer care deficiency. |
| Staff K | Registered Nurse (RN) | Named in pressure ulcer care deficiency. |
| Staff L | Certified Medication Aide (CMA) | Named in pressure ulcer care deficiency. |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including care plans, elopement, pressure ulcer, infection control, and documentation. |
| DO | Doctor of Osteopathic Medicine | Named in pressure ulcer treatment and assessment. |
| ARNP | Accredited Registered Nurse Practitioner | Named in pressure ulcer treatment and assessment. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 18, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction, indicating acceptance of the facility's credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction, resulting in certification effective January 18, 2024.
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Jan 10, 2024
Visit Reason
The inspection was conducted as a result of the facility's investigation of complaints #117880-C, #117815-A and facility reported incident #117829-M from January 2, 2024 to January 10, 2024. Complaint #117815-A and incident #117829-M were substantiated.
Findings
The facility failed to assure residents were treated with respect and dignity, exposing 4 of 6 residents reviewed (Residents #4, #5, #6, and #7) to social media abuse by a staff member. Evidence included pictures and videos showing residents in vulnerable states without consent, violating resident rights.
Complaint Details
Complaint #117815-A was substantiated. Incident #117829-M was substantiated. The investigation included record review, staff, resident, and family interviews, and review of facility policy.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assure residents were treated with respect and dignity, exposing residents to social media abuse by staff. | SS=E |
Report Facts
Resident census: 108
Residents reviewed: 6
Residents affected: 4
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 25, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective October 25, 2023.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 5
Oct 9, 2023
Visit Reason
Investigation of complaints #115272-C, #115161-C, facility reported incident #115686-I, the revisit of the recertification survey ending on June 29, 2023, and a revisit on complaints and facility reported incident ending on August 8, 2023.
Findings
The facility was found deficient in multiple areas including failure to transfer residents safely as per care plans, inadequate incontinence care, insufficient nursing staff to meet resident needs and respond to call lights timely, ineffective quality assurance and performance improvement program, and failure to maintain infection prevention and control practices.
Complaint Details
Complaints #115272-C was substantiated. Complaint #115161-C and facility reported incident #115686-I were unsubstantiated.
Severity Breakdown
SS=D: 2
SS=E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to transfer residents as directed by care plans and failed to use gait belts appropriately during transfers. | SS=D |
| Failed to provide incontinence care to prevent cross contamination and failed to properly care for catheter and nephrostomy tubes. | SS=D |
| Failed to provide sufficient nursing staff to meet residents' needs and respond to call lights timely. | SS=E |
| Failed to implement an effective, comprehensive Quality Assurance Performance Improvement (QAPI) program addressing repeat deficiencies and quality of care issues. | SS=E |
| Failed to maintain infection prevention and control practices including hand hygiene, glove use, disinfecting surfaces, and proper handling of soiled linens. | SS=E |
Report Facts
Residents census: 104
Call light response times: 15
Call light response delays: 105
Licensed nurses per shift: 2
Nurse aides per shift: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Braden | Executive Director | Signed plan of correction and provided interview regarding QAPI and survey responses. |
| Staff A | Certified Nursing Assistant | Observed transferring residents and providing incontinence care with deficiencies. |
| Staff B | Licensed Practical Nurse | Observed performing wound care with improper infection control practices. |
| Staff C | Licensed Practical Nurse | Assisted with wound care and dressing changes with improper infection control practices. |
| Staff D | Certified Nursing Assistant | Observed carrying soiled linens improperly and received counseling. |
| Director of Nursing | Provided multiple interviews regarding expectations for staff practices and deficiencies. | |
| LTC Ombudsman | Reported resident concerns about call light response times. | |
| Social Workers | Conducted call light audits and monitored staff response times. | |
| Activities Director | Attended resident council meetings and documented resident concerns. |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 4
Aug 8, 2023
Visit Reason
Investigation of Complaint #114487-C and Facility Reported Incident #114488-I conducted from July 31, 2023 to August 8, 2023. Complaint and incident were substantiated.
Findings
The facility failed to follow physician orders for medication administration for 4 residents, including crushing morphine extended release and administering incorrect doses of dexamethasone and narcotics. The facility also failed to document adequate assessments after medication errors for 2 residents and failed to answer call lights timely for 5 residents. Significant medication errors were identified, including administration of narcotics without orders and wrong eye drops given to a resident.
Complaint Details
Complaint #114487-C and Facility Reported Incident #114488-I were substantiated. The investigation focused on medication errors and resident care issues.
Severity Breakdown
SS=E: 2
SS=D: 1
SS=J: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to follow physician orders for medication administration including crushing morphine extended release and administering incorrect doses. | SS=E |
| Failed to document adequate assessments after medication errors for 2 residents. | SS=D |
| Failed to answer call lights in a timely manner for 5 residents. | SS=E |
| Significant medication errors including crushing morphine ER, administering incorrect steroid dose, and giving narcotic without order. | SS=J |
Report Facts
Residents present: 108
Morphine dose: 90
Dexamethasone dose: 16
Medication errors: 4
Call light response time: 90
Medication doses: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | LPN | Administered crushed morphine extended release to Resident #1 and involved in medication error |
| Staff D | RN | Reported on Resident #1 care and medication administration |
| Staff K | CMA | Administered unauthorized PRN narcotic dose to Resident #3 |
| Staff M | RN | Reported on medication error prevention and staffing issues |
| Staff B | Nurse Practitioner | Documented care for Resident #1 after medication error |
| DON | Director of Nursing | Provided interviews regarding staffing, medication errors, and call light response |
| ADON | Assistant Director of Nursing | Provided interviews regarding medication errors, staffing, and call light response |
| Consultant Pharmacist | Provided interview regarding risks of crushing morphine extended release |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 16
Jun 29, 2023
Visit Reason
Annual Recertification Survey and investigation of multiple complaints and facility reported incidents.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, advance directive documentation, environmental safety and temperature control, comprehensive care planning, bathing and ADL care, transfer assistance, infection prevention and control, antibiotic stewardship, immunization education, and timely reporting of major injuries.
Severity Breakdown
SS=D: 9
SS=E: 4
SS=C: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to provide care for 2 of 26 residents in a manner to promote dignity and respect. | SS=D |
| Failed to accurately document advance directives for 1 of 7 residents reviewed. | — |
| Failed to maintain comfortable temperature in dining room; temperatures recorded above regulatory limits. | SS=E |
| Failed to develop and implement comprehensive care plan for 1 of 26 residents. | SS=D |
| Failed to revise care plan for 1 of 2 residents with catheter. | SS=D |
| Failed to provide routine bathing per residents' wishes for 5 of 5 residents reviewed. | SS=E |
| Failed to provide appropriate level of transfer assistance and supervision for 1 of 1 resident reviewed. | SS=D |
| Failed to ensure complete and appropriate incontinence care and hand hygiene for multiple residents. | SS=D |
| Failed to complete monthly medication regimen review by licensed pharmacist for 3 of 5 residents. | SS=D |
| Failed to serve all foods at palatable temperatures for 1 of 3 meal services observed. | SS=E |
| Failed to establish and maintain infection prevention and control program consistent with accepted standards, including hand hygiene and glove use. | SS=D |
| Failed to have a qualified Infection Preventionist with required certification. | SS=C |
| Failed to provide education on influenza vaccination prior to refusal for 2 of 5 residents. | SS=D |
| Failed to report a major injury to the Department of Inspections and Appeals for 1 of 7 residents reviewed. | — |
| Failed to repair roof damage causing unsafe environment including water damage, ceiling collapse, and mold. | SS=E |
| Failed to provide sufficient nursing staff to respond to call lights timely for 1 of 5 residents reviewed. | — |
Report Facts
Residents reviewed: 26
Residents reviewed: 7
Temperature: 85
Temperature: 90
Residents reviewed: 5
Residents reviewed: 1
Residents reviewed: 4
Residents reviewed: 5
Residents reviewed: 3
Residents reviewed: 7
Residents reviewed: 3
Residents reviewed: 6
Residents reviewed: 5
Residents reviewed: 3
Residents reviewed: 3
Residents reviewed: 3
Residents reviewed: 3
Residents reviewed: 5
Residents reviewed: 3
Residents reviewed: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 20, 2022
Visit Reason
The document serves as a plan of correction following a survey to address deficiencies and certify compliance with 42 CFR Part 483, Subpart B-C.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective September 20, 2022.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
Aug 19, 2022
Visit Reason
The inspection was conducted as an investigation of complaints #105317-C, #105755-C, #106434-C, and #106521-C between August 11, 2022 and August 18, 2022.
Findings
The facility was found to have failed to provide adequate communication means for a hearing-impaired resident (Resident #25) and failed to provide fresh ice water for hydration to two residents (Resident #6 and Resident #25). One complaint (#106521-C) was substantiated while the others were not. The facility implemented corrective actions including use of whiteboards for communication and hydration protocols.
Complaint Details
Investigation of complaints #105317-C, #105755-C, #106434-C, and #106521-C. Complaints #105317-C, #105755-C, and #106434-C were not substantiated. Complaint #106521-C was substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide adequate means of communication to assist a hearing-impaired resident (Resident #25). | SS=D |
| Failed to provide fresh ice water for hydration to 2 residents (Resident #6 and Resident #25). | SS=D |
Report Facts
Resident census: 104
Brief Interview for Mental Status (BIMS) score: 7
Brief Interview for Mental Status (BIMS) score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Braden | Executive Director | Signed the plan of correction and mentioned in relation to the facility's corrective actions. |
| Staff D | Director of Social Services | Reported no communication plan was in place for Resident #25 until 8/17/22. |
| Staff E | Certified Nurse Aide (CNA) | Observed communicating with Resident #25 by leaning close and speaking loudly. |
| Staff C | Certified Nurse Aide (CNA) | Reported Resident #25 was very hard of hearing and required repeated questions. |
| Staff B | Shower Aid | Reported having to lean down and speak loudly to Resident #25 and never used paper and pen for communication. |
| Staff A | Certified Nurse Assistant (CNA) | Reported residents receive fresh ice water when they ask for it and described hydration routines. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 18, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Bishop Drumm Retirement Center, certifying compliance based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was found to be in compliance effective 6/18/22 based on the acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 113
Deficiencies: 7
May 19, 2022
Visit Reason
The inspection was conducted as the facility's annual health survey in conjunction with an investigation of multiple complaints.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity and privacy, unsafe and unclean environment, failure to revise care plans timely, medication administration errors, inadequate ADL care, failure to monitor dialysis residents properly, and lapses in infection prevention and control practices.
Complaint Details
The inspection included an investigation of complaints 97103, 99964, 100310, 101656, 101989, 103333, 103607, 103644, 103970, and 104282. Complaints 97103, 99964, 100310, 101656, 103333, 103607, 103644, 103970, and 104282 were substantiated. Complaint 101989 was not substantiated.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide an environment that maintained a resident's privacy and preserved dignity (Resident #3). | SS=D |
| Failure to provide a safe, clean, comfortable, and homelike environment including maintenance issues and urine on floors. | SS=E |
| Failure to revise a resident's care plan to reflect changes in status related to skin breakdown (Resident #98). | SS=D |
| Failure to ensure staff followed professional standards of practice with medication administration and physician orders (Residents #47, #20, #105). | SS=D |
| Failure to provide at least two baths per week as scheduled for dependent residents (Residents #47 and #90). | SS=D |
| Failure to complete full nursing assessments and monitoring before and after outpatient dialysis treatments (Resident #55). | SS=D |
| Failure to follow infection control protocols including improper catheter care, catheter bag placement, and floor cleanliness (Residents #17, #40, #52, #109). | SS=E |
Report Facts
Residents reviewed: 9
Residents reviewed for care plan: 27
Medication tablets found: 71
BIMS scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Certified Nursing Assistant | Interviewed regarding toileting rounds and incontinence care |
| Staff B | Certified Nursing Assistant | Observed providing catheter care and interviewed about bathing schedules |
| Staff H | Certified Nursing Assistant | Observed providing wound care and catheter care, interviewed about bathing and incontinence care |
| Staff I | Registered Nurse | Observed providing wound care and interviewed about bathing |
| Staff K | Certified Medication Aide | Reported finding medication hoard in Resident #20's room |
| Staff L | Assistant Director of Nursing | Interviewed about medication incident and expectations for medication administration |
| Staff F | Assistant Director of Nursing | Interviewed about dialysis monitoring expectations |
| Staff J | Housekeeping | Interviewed about floor cleaning practices |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding care plan revisions, medication administration, bathing, catheter care, and dialysis monitoring |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 10
Feb 24, 2021
Visit Reason
The facility recertification survey and investigation of complaints #94194-C, #94195-C, #95536-C, and #94641-C completed on February 9-24, 2021.
Findings
The survey found multiple deficiencies related to resident self-administration of medications, safe and homelike environment, accuracy of assessments, coordination of PASRR and assessments, services meeting professional standards, treatment and services to prevent pressure ulcers, bedrails safety, infection prevention and control, food procurement and safety, and resident call system. Several residents were observed with unmet needs and safety risks.
Complaint Details
Complaints #94194-C, #94195-C, and #95536-C were substantiated; complaint #94641-C was not substantiated.
Deficiencies (10)
| Description |
|---|
| Failed to provide ongoing assessments, care planning, and physician orders for residents to self-administer medications. |
| Failed to assure a safe, clean, comfortable and homelike environment for residents. |
| Failed to accurately complete Minimum Data Set assessments for residents. |
| Failed to coordinate PASRR and assessments for residents with serious mental illness or intellectual disability. |
| Failed to provide services meeting professional standards for residents, including diabetes management and bowel care. |
| Failed to provide treatment and services to prevent and heal pressure ulcers. |
| Failed to assess and ensure safety of bed rails and obtain consent for use. |
| Failed to establish and maintain an infection prevention and control program. |
| Failed to maintain sanitary conditions in food procurement, storage, preparation, and serving. |
| Failed to provide an adequate resident call system accessible to residents. |
Report Facts
Facility census: 124
Number of residents reviewed for self-administered medications: 17
Number of residents reviewed for accuracy of assessments: 25
Number of residents reviewed for accuracy of assessments: 25
Number of residents reviewed for assistance with activities of daily living: 7
Number of residents reviewed for infection control: 32
Number of residents reviewed for call system accessibility: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Sweet | Executive Director | Signed the plan of correction on 4/3/21. |
| Staff G | Certified Medication Aide (CMA) | Observed preparing and administering medications to residents. |
| Director of Nursing (DON) | Provided education and oversight on medication self-administration and infection control. | |
| Staff X | MDS Coordinator | Reviewed clinical records and assessments for residents. |
| Staff R | Director of Facilities | Reported on maintenance and safety issues. |
| Staff H | Certified Nurses' Aide (CNA) | Observed providing care and education on nebulizer treatments. |
| Staff J | Registered Nurse (RN) | Administered medications and monitored resident care. |
| Staff S | Infection Preventionist (IP) | Provided infection control observations and education. |
| Staff T | Certified Medication Aide (CMA) | Observed providing medication and infection control. |
| Staff F | Certified Nurses' Aide (CNA) | Observed providing resident care and infection control. |
| Staff M | Certified Nurses' Aide (CNA) | Observed providing resident care and infection control. |
| Staff W | Certified Nursing Assistant (CNA) | Reported housekeeping and food safety observations. |
| Staff E | Culinary Support | Observed preparing and serving food. |
| Staff U | Certified Medication Aide | Reported dietary staff observations. |
| Staff V | Housekeeper | Reported refrigerator cleaning observations. |
| Staff Q | Licensed Practical Nurse (LPN) | Reported on resident care and side rails. |
| Staff B | Certified Nurses' Aide (CNA) | Observed providing resident care and infection control. |
| Staff N | Registered Nurse (RN) | Reported on resident pain management. |
| Staff P | Certified Nurses' Aide (CNA) | Reported on resident pain management and interventions. |
| Staff L | Certified Nurses' Aide (CNA) | Responded to resident care observations. |
Inspection Report
Abbreviated Survey
Census: 119
Deficiencies: 0
Nov 24, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 119
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Oct 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted along with an investigation of multiple complaints and self-reported facility incidents between 9/21/2020 and 10/6/2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The complaints and self-reported incidents were not substantiated.
Complaint Details
Investigation of Complaints #87533, #87949, #90666, #90670, #90761, #91065, #91113, and #93464, as well as Self-Reported Facility Incidents #91000 and #93478, all were not substantiated.
Report Facts
Total Census: 120
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Jun 25, 2020
Visit Reason
An onsite COVID-19 Focused Infection Control Survey and the investigation of Complaints #90753, #90849, and #91027 was conducted by the Department of Inspections and Appeals from 6/23/20 through 6/25/20.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The complaints were not substantiated.
Complaint Details
Complaints #90753, #90849, and #91027 were investigated and found to be not substantiated.
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