Bishop Drumm Retirement Center

In the surveyor’s words

From the most serious findings on record at Bishop Drumm Retirement Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Aug 18, 2024

  Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to prevent the development of a pressure ulcer for 1 of 3 (Resident #1) residents reviewed. The resident was admitted with one Stage IV pressure ulcer, having comorbidities which made her susceptible to further impaired skin integrity. The facility failed to provide recommended every 2 hour repositioning, and failed to do all ordered skin treatments. This failure resulted in Immediate Jeopardy to the health and safety of the resident when she developed a second stage IV pressure ulcer, which required multiple antibiotics and medical intervention during a hospital. The facility reported a census of 119 residents. […]

• Immediate jeopardy, isolatedF686Feb 27, 2024

  Based on observations, clinical record review, staff interviews, provider interviews and facility policy review the facility failed to provide skin assessments per policy and provide treatments per physician's orders to prevent the development and worsening of a facility acquired pressure ulcer which required the physician to complete a debridement of a Stage IV pressure ulcer to the coccyx for 1 of 3 residents (Resident #11) reviewed for pressure ulcers. There was an immediate need for the facility to take steps to ensure residents were protected from risk of development or worsening of wounds. The facility reported a census of 110 residents. […]

• Immediate jeopardy, isolatedF760Aug 8, 2023

  Based on staff interview, pharmacist interview, physician interview, clinical record review and facility policy review, the facility failed to prevent significant medication errors which included: Staff A, LPN crushed morphine extended release medication 90 milligrams (mg) and administered it to Resident #1. The facility also administered 16 mg of Dexamethasone (steroid) instead of 4 mg as ordered for Resident #2. Additionally, Resident #3 received a narcotic medication on an as needed dose without an order. On 8/2/23 at 1:30 PM, the State Agency (SA) notified the Administrator and Director of Nursing (DON) of the Immediate Jeopardy of F 760 significant medication error. […]

• Actual harm, isolatedF686Sep 17, 2025

  Based on clinical record reviews, hospital clinical record review, hospital images, staff interviews and policy review the facility failed to identify a resident with a pressure ulcer/injury and to assure the resident received treatment and services, consistent with professional standards of practice, to promote healing of an unstageable pressure ulcer/injury for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 114 residents.Finding include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. […]

• Actual harm, isolatedF688Jul 21, 2025

  Based on record review, observations, and family and staff interviews, the facility failed to carry out therapy recommendations and provide restorative exercises for 1of 4 residents reviewed for rehabilitation services and/or limited range of motion (Resident #10). The facility reported a census of 107 residents. Findings include:The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had diagnoses of dementia, mild intellectual disability, and failure to thrive. The MDS documented the resident required set-up assistance for eating, partial to maximum assistance for bed mobility, and had dependence on staff for transfers and toileting. The MDS indicated the resident's upper and lower extremity range of motion (ROM) not impaired. […]