Inspection Reports for
Bishop Drumm Retirement Center

The visit was a revisit following investigation of complaints #2577057-C, #2580711-C, #2612229-C, and #2612253-C, which resulted in deficiencies.

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.

The visit was complaint-related, triggered by allegations of failure to notify family of significant changes, failure to obtain ordered weekly weights, inadequate pressure ulcer care, improper catheter care, improper feeding tube medication administration, delayed call light response, and infection control deficiencies. The facility was found to have substantiated deficiencies in these areas.

The facility failed to notify family of significant resident condition changes, did not obtain weekly weights as ordered for residents with feeding tubes, failed to provide appropriate pressure ulcer care including documentation and treatment, did not provide proper suprapubic catheter care, failed to flush feeding tubes before and after medication administration, had delayed call light responses and call lights out of reach, and failed to maintain infection control practices including proper use of enhanced barrier precautions and hand hygiene.

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.

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.

The facility was found to have multiple deficiencies including failure to maintain a safe, clean, and homelike environment, inadequate reporting and assessment of resident skin conditions, delayed response to call lights, and failure to follow infection prevention and control practices for residents with feeding tubes and catheters. All deficiencies were assessed as minimal harm or potential for actual harm affecting a few residents.

The facility was found deficient in multiple areas including failure to document accurate advanced directives, maintain a safe and homelike environment, notify the LTC Ombudsman of hospitalizations, develop and implement comprehensive care plans, conduct care conferences with legal guardians, report changes in resident condition and perform skin assessments, carry out therapy recommendations and restorative exercises, respond timely to call lights, and follow infection prevention and control practices.

The complaint investigation found substantiated issues related to failure to notify medical providers timely for Resident #2 and inadequate supervision leading to a fall for Resident #3.

The facility failed to promptly notify a medical provider about Resident #2's hyperglycemia and elevated heart rate, resulting in hospitalization for sepsis and diabetic ketoacidosis. Additionally, the facility failed to provide adequate supervision for Resident #3, resulting in a fall causing a skin tear and pain, with delayed and incomplete care following the incident.

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.

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.

The facility failed to perform required post dialysis assessments and monitor side effects of missed medications for Resident #2, failed to document timely post-fall assessments for Resident #9, did not ensure proper transfer techniques for residents requiring mechanical lifts, had delayed responses to call lights affecting resident safety, and failed to maintain an effective pest control program resulting in mouse sightings in resident rooms.

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.

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.

The inspection included investigation of Complaints #123184-C and Facility Reported Incidents #123367-I.

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.

The facility was found deficient in multiple areas including failure to treat residents with dignity due to staff arguing in front of residents, inadequate nutritional interventions for a resident with significant weight loss, failure to secure resident health information, and lapses in infection control practices including improper catheter care, failure to use personal protective equipment, and inadequate hand hygiene during medication administration.

The facility failed to secure Electronic Health Record information for 16 residents, with a northeast hall report sheet containing 21 residents' information observed face up on a medication cart, contrary to facility policy.

Complaint #122063-C was substantiated.

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.

The complaint investigation found that the facility failed to prevent pressure ulcer development in Resident #1, who was admitted with one Stage IV pressure ulcer but developed a second Stage IV ulcer due to inadequate care. The immediate jeopardy began on June 9, 2024, and was removed on August 18, 2024 after corrective actions were implemented.

The facility failed to provide appropriate pressure ulcer care and prevention, including recommended repositioning and ordered skin treatments, leading to the development of a second Stage IV pressure ulcer in Resident #1. The resident required hospitalization and multiple antibiotics. The facility implemented corrective actions including skin assessments, policy updates, staff education, and audits to remove immediate jeopardy.

Complaints #120667-C was unsubstantiated. Complaints #120746-C, #121577-C, and #121674-C were substantiated based on record review, staff interviews, and policy review.

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.

The complaint investigation revealed repeated deficiencies related to pressure ulcer care (F686) and staffing (F725), with substantiated findings of actual harm to residents due to pressure ulcers and minimal harm or potential harm due to inadequate staffing and ineffective quality assurance.

The facility failed to provide adequate care to prevent pressure ulcers in two residents at risk, had insufficient nursing staff to meet resident needs, and lacked an effective quality assurance program to ensure compliance with regulations and quality care.

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.

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.

The facility failed to ensure the dignity of Resident #3 by allowing her to sit in the commons area with an exposed adult brief and inadequate grooming. The facility also failed to initiate physician orders for two residents, including medication administration delays and omissions. Additionally, Resident #3 did not consistently receive assistance with activities of daily living as required.

The facility failed to implement a comprehensive care plan for a resident with elopement risk, failed to ensure treatment orders were signed out and initiated for some residents, failed to provide appropriate pressure ulcer care resulting in a Stage IV pressure ulcer requiring debridement, failed to complete elopement risk assessments timely, failed to maintain complete bathing records for some residents, and failed to follow infection control practices during incontinent cares.

Complaints #118595-C and #118876-C were substantiated.

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.

The complaint investigation substantiated that residents #4, #5, #6, and #7 were exposed to social media abuse by staff members, including unauthorized photos and videos with inappropriate captions. Family members confirmed expectations for dignity and respect were not met.

The facility failed to ensure residents were treated with dignity and respect, as evidenced by social media posts showing residents in compromising situations without consent. Four of six residents reviewed were affected, with videos and pictures taken without permission and inappropriate captions.

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.

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.

The visit was complaint-related, triggered by concerns about resident transfers, incontinence care, catheter care, staffing shortages, call light response times, quality assurance failures, and infection control breaches. The facility reported a census of 104 residents. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including improper resident transfer techniques, inadequate incontinence and catheter care, insufficient staffing leading to delayed call light responses, ineffective quality assurance processes, and failure to maintain infection prevention and control standards.

Complaints #115272-C was substantiated. Complaint #115161-C and facility reported incident #115686-I were unsubstantiated.

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 #114487-C and Facility Reported Incident #114488-I were substantiated. The investigation focused on medication errors and resident care issues.

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.

The complaint investigation was triggered by reports of medication errors including crushing morphine extended release medication, administering incorrect doses of dexamethasone, and giving narcotic medication without an order. Additional complaints involved inadequate assessments after medication errors and delayed response to call lights. Immediate jeopardy was identified related to medication errors on 7/24/23 and removed on 8/3/23 after corrective actions.

The facility failed to follow physician orders for medication administration for 4 residents, including crushing morphine extended release and administering incorrect doses. The facility also failed to document adequate assessments after medication errors for 2 residents and failed to answer call lights in a timely manner for 5 residents. Immediate jeopardy was identified related to significant medication errors but was removed after corrective actions were implemented.

The facility was found deficient in multiple areas including failure to provide dignified care to residents, inaccurate documentation of advance directives, inadequate temperature control in dining areas, failure to revise care plans timely, insufficient bathing per resident wishes, improper transfer assistance, lack of restorative therapy, unresolved roof damage causing water intrusion and mold, insufficient nursing staff to meet resident needs, serving food at improper temperatures, and failure to implement proper infection prevention and control practices.

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.

The facility was found deficient in multiple areas including failure to provide dignified care, inadequate documentation of advance directives, uncomfortable dining room temperatures, incomplete care plans, insufficient bathing per resident wishes, improper transfer assistance, lack of restorative therapy, unresolved building damage and water intrusion, incomplete incontinence care, insufficient nursing staff to meet call light needs, missing monthly medication regimen reviews, serving food at improper temperatures, inadequate infection prevention and control practices, ineffective antibiotic stewardship, unqualified infection preventionist, and failure to provide influenza vaccination education.

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.

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.

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.

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.

Complaints #94194-C, #94195-C, and #95536-C were substantiated; complaint #94641-C was not substantiated.

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.