Bishop Drumm Retirement Center

Inspectors wroteBased on clinical record review, family and staff interviews, and policy review, the facility failed to provide timely notification to the son (Durable Power-of-Attorney - DPOA) for 1 of 3 residents (#2) who repeatedly refused critical medication. The facility reported a census of 119 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to provide post-fall assessments and interventions for 2 of 3 residents (#2, #5). The facility reported a census of 119.

Inspectors wroteBased on photographs, family and staff interviews, and policy review, the facility failed to provide adequate nursing supervision by not preventing a Certified Nurse Aide (CNA) from sleeping while on-duty. The facility reported a census of 119 residents.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 119 residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access by leaving 6 residents' information unsecured and visible when staff left a report sheet face-up on the medication cart when the staff walked away. The facility reported a census of 119 residents.

Inspectors wroteBased on observations, staff interview, and policy review the facility failed to use infection prevention standards when staff failed to cover clean linen when transported in a resident hall and failed to don appropriate Personal Protective Equipment (PPE) when providing personal care for a resident on Enhance Barrier Precautions (EBP) (#8). The facility reported a census of 119 residents.

Inspectors wroteBased on direct observation, clinical record review, resident and staff interview, and facility policy review, the facility failed to maintain adequate staffing levels resulting in excessively long call-light times reported by residents, reports of staff members sleeping on the job, the North East Dining room being closed due to low staffing, and the Director of Nursing (DON) working the floor as a charge nurse when prohibited. The facility reported a census of 124.

Inspectors wroteBased on clinical record review, resident and staff interview, and facility policy review, the facility failed to prevent the Director of Nursing (DON) from serving as a charge nurse when a facilities daily average census exceeds 60 residents. The facility reported a census of 124. Findings Include: In an interview on 02/12/2026 at 09:12 AM with Staff P, Registered Nurse (RN), she stated the facility is under staffed and the DON has been working nights and overnight shifts to help cover staffing. She confirmed the DON was serving in her role as a charge nurse. In an interview on 02/12/2026 at 9:36 AM with Staff Q, RN, she confirmed the DON has been working as a charge nurse alongside the Assistant Executive Director and other nursing leadership to cover staffing shortfalls in the facility. [...]

Inspectors wroteBased on review of The State Survey Agency website found at https://dia-hfd.iowa.gov/, staff interview, and review of the facility QAPI (Quality Assurance Performance Improvement) plan, the facility failed to ensure an effective process to address previously identified quality deficiencies. This resulted in the facility receiving an Insufficient Nursing Staff deficiency for the fifth time in a two-year period. The facility reported a census of 124 residents. Findings Include:Review of the State Agency's public website https://dia-hfd.iowa.gov/ contained the following certification actions during the following surveys: Ending on 09/17/2025 resulted in a deficiency cited related to staffing. Ending on 07/21/2025 resulted in a deficiency cited related to staffing. Ending on 04/03/2025 resulted in a deficiency cited related to staffing. [...]

Inspectors wroteBased on observations, staff interview, and policy review the facility failed to use infection prevention standards to secure a resident's indwelling catheter tubing (#4), failed to maintain equipment in a manner to prevent cross-contamination, and failed to don appropriate Personal Protective Equipment (PPE) when providing wound care for a resident on Enhance Barrier Precautions (EBP) (#12). The facility reported a census of 124 residents.

Inspectors wroteBased on direct observation, clinical record review, resident and staff interview the facility failed to provide dignified grooming for residents who requested it in 1 of 15 residents surveyed (Resident #2). The facility reported a census of 124.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to provide timely physician and family notification for 1 of 1 resident (#8) who experienced a change in condition or treatment. The facility reported a census of 124 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to provide assessment and interventions for 1 of 1 resident (#8) who experienced an elevated temperature and a change in mental condition. The facility reported a census of 124 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to apply foot pedals to a resident's wheelchair during transport for 1 of 1 resident (#8). The facility reported a census of 124 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to correctly administer insulin by failing to prime a newly attached insulin pen needle before administering it for 1 of 3 residents (#14) and verifying documented open date for 2 of 3 residents (#14, #15), and attempted to administer a medication without an order for 1 of 3 residents (#8). The facility reported a census of 124 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to provide an accurate health record for a change in condition for 1 of 1 resident (#8). The facility reported a census of 124 residents.

Inspectors wroteBased 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.

Inspectors wroteBased on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past surveys, and staff interview, the facility failed to correct their own deficiencies and have an effective quality assurance program in place to assist in the provision of quality of care for residents and attain substantial complaining with Federal regulation and State rule. The facility reported a census of 114 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to notify the family/emergency contact when a resident had a significant change of condition for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 114 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to provide care and services according to accepted standards of clinical practice for 3 of 3 residents reviewed (Residents #10, #76, #15). The facility failed to obtain weekly weights per physician order for residents who have a feeding tube. The facility reported a census of 114 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review the facility failed to provide appropriate suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) care for 1 of 3 residents (Resident #15) reviewed. The facility reported a census of 114 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review the facility failed to flush an enteral gastrostomy tube (g-tube) (tube surgically inserted into the stomach to provide nutrition and medication) per facility policy prior to and after administering medication thru the g-tube for 1 of 3 resident (Resident #15) reviewed. The facility reported a census of 114 residents.

Inspectors wroteBased on resident council minutes review, resident and staff interviews, record review, and policy review the facility failed to answer call lights in a timely manner (15 minutes or less) for 3 of 3 residents (Residents #26, #39, and #79) reviewed and failed to ensure the call light was within reach for 2 of 5 residents (Residents #1 and #15) reviewed. The facility reported a census of 114 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 1 of 5 residents reviewed (Resident #15). The facility failed to ensure use of enhanced barrier precautions (EBP)when required and failed to complete hand hygiene and change gloves when completing treatments. The facility reported a census of 114 residents.

Inspectors wroteBased 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.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to document an accurate code status for one of thirty-two residents sampled for advanced directives (Resident #11). The facility reported a census of 107 residents.

Inspectors wroteBased on observations, facility work orders, resident and staff interviews, and policy review, the facility failed to provide a safe, clean, comfortable and homelike environment. The facility identified a census of 107 residents.

Inspectors wroteBased on clinical record review, facility record review and staff interview, the facility failed to provide notification to the Long Term Care (LTC) Ombudsman for 1 of 3 (Resident #1) reviewed. The facility reported a census of 107 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 23 residents sampled (Resident #100 and #62). The facility reported a census of 107 residents.

Inspectors wroteBased on clinical record review, resident representative interview, staff interviews and facility policy review, the facility failed to conduct resident care conferences and offer the resident's Legal Guardian (an individual appointed by the court to make decisions for another person, known as the protected person, who is unable to care for themselves due to physical or cognitive limitations) to participation in their plan of care for 1 of 1 residents reviewed (Resident #3) . The facility reported a census of 107 residents.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, and policy review the facility failed to report a resident's change in condition, and failed to assess and document a skin assessments for one of three residents reviewed (Resident #5). The facility reported a census of 107 residents.

Inspectors wroteBased on Resident council minutes, family interview, resident interview, and staff interview the facility failed to answer call lights in a timely manner (15 minutes or less) for 3 of 4 units (North, South and North East). The facility reported a census of 107 Residents.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to follow infection control practices for a resident with a feeding tube for 1 of 3 residents reviewed for medication review (Resident #79). The facility also failed to follow infection control practices for a resident with a catheter for 1 of 1 resident reviewed for catheter care (Resident #19). The facility reported a census of 107 residents.

Inspectors wroteBased on clinical record review, hospital record review, staff and physician interview, the facility failed to promptly notify a medical provider in a timely manner of a change of condition for 1 of 4 residents reviewed (Resident #2). Resident #2 was exhibiting symptoms of hyperglycemia (high blood sugar) two days prior to physician notification and had an elevated heart rate for several days prior. The resident was hospitalized with diagnoses including sepsis (infection in the bloodstream) and diabetic ketoacidosis (also known as DKA, a serious complication of diabetes causing a buildup of ketones and a significant rise of blood sugar). The facility reported a census of 117 residents.

Inspectors wroteBased on observations, clinical record review, staff interview and facility policy review, the facility failed to provide adequate supervision and follow the care plan for 1 of 3 residents reviewed, resulting in Resident #3 suffering a fall. The facility reported a census of 117 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility policy review, the facility failed to perform post dialysis assessment and failed to assess for side effects of missed medication doses for Resident #2 on 3/22/25. Resident #2 later transferred to the hospital on 3/22/25 for abnormal vital signs, lethargy, and hypothermia. Resident#2 was 1 of 3 residents reviewed for assessment and intervention. The facility additionally failed to document a post fall assessment, greater than 24 hours, following a fall on 4/02/25 (Resident #9) for a witnessed fall without injury. Resident#9 was 1 of 3 residents reviewed for falls. The facility reported a census of 119 residents.

Inspectors wroteBased on record review, observation, policy review, resident interview and staff interview the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents reviewed (Resident #3 and #7) requiring mechanical equipment device transfers. The facility reported a census of 117 residents.

Inspectors wroteBased on observation, electronic health record (EHR) review, resident interview and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 6 resident reviewed (Resident #5, #6, #7 and #11). The facility reported a census of 117 residents.

Inspectors wroteBased on observation, Electronic Health Record review (EHR), resident interviews and staff interviews the facility failed to maintain an effective pest control program so that the facility was free of pest and rodents for 2 of 3 residents reviewed (Resident #1 and #10). The facility reported a census of 117 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 3 residents (Resident #69) reviewed for nutrition. This failure resulted in harm due to Resident #69 experiencing a weight loss of 10.4% in an approximate 3 month period. The facility reported a census of 120 residents. Findings Include: The Quarterly Minimum Data Set (MDS) of Resident #69, dated 8/15/24 identified a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS identified a PHQ-9 (Patient Health Questionnaire) score of 13, indicating moderate depression. The MDS documented diagnoses that included: anemia (low red blood cell count), renal (kidney) insufficiency), diabetes, dementia, and depression. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to treat residents with dignity by staff arguing with each other in front of 9 residents. The facility reported a census of 120.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to secure Electronic Health Record information for 16 residents. The facility reported a census of 120.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to implement infection control practices to minimize cross-contamination for 9 of 9 resident staff interactions reviewed for infection control observations (#31, 52, 61, 63,64,113, 114, and 324). The facility reported a census of 120.

Inspectors wroteBased 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. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/17/24 at 4:05 pm. The IJ began on June 9, 2024. [...]

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to provide the care, interventions, and services to prevent the development of a pressure sore for 2 of 6 residents sampled as at risk for pressure ulcer development, (Resident #1 and #2). The facility reported a census of 116.

Inspectors wroteBased on observations, resident, family, and staff interviews, record review, facility assessment, and policy review, the facility failed to provide sufficient staff to meet the residents' needs for cares and answer call lights timely for 2 of 3 nursing units. The facility reported a census of 116 residents.

Inspectors wroteBased on facility record review, policy review, and staff interview, the facility failed to have an effective quality assurance (QA) program in place to assist in the provision of quality care for residents and attain substantial compliance with Federal regulations and State rules. The facility identified a census of 116 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews facility policy review the facility failed to ensure the dignity of 1 of 3 residents (#3) was respected while she sat in the commons area with peers. The facility reported a census of 110 residents.

Inspectors wroteBased on record review, staff and hospital staff interviews, and policy review the facility failed to initiate 2 of 3 resident's (Resident #1 & #2) physician's orders. Resident #1 was seen by the wound physician weekly with recommendations that were not initiated. Resident #2 was a newly admitted resident to the facility. The facility failed to administer his medications as ordered. The facility reported a census of 110 residents.

Inspectors wroteBased on observations, record review, staff interviews, and policy review the facility failed to ensure 1 of 3 residents (Resident #3) received assistance with their activities of daily living (ADLS). The facility reported a census of 110 residents.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observations, clinical record review, staff interview and facility policy review the facility failed to implement a comprehensive care plan for 1 of 3 residents (Resident #5) reviewed for elopement. The facility reported a census of 110 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice regarding signing out ointment treatments as being completed and initiating physician's orders for 2 or 3 residents reviewed (Resident #4 and #11). The facility reported a census of 110.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review the facility failed to ensure 1 of 3 residents (Resident #5) was assessed for an elopement risk after he left the building on 2/13/24. The facility reported a census of 110 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to ensure Resident #6, #7, and #8 medical record contained bath records and Resident #11 medical record contained completed skin assessments. The facility reported a census of 110 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review the facility failed to follow infection control practices while completing incontinent cares for 1 of 3 residents (Resident #14). The facility reported a census of 110 residents.

Inspectors wroteBased on record review, staff, resident, and family interview, along with facility policy, the facility failed to assure residents were treated with respect and dignity for which residents were exposed to social media for 4 of 6 residents reviewed (Resident #4, #5, #6, and #7). The facility reported a census of 108 residents.

Inspectors wroteBased on resident interviews, resident council minutes, facility call light audits, facility assessment, policy review, and staff interviews the facility failed to provide sufficient staff to meet the residents' needs and answer call lights timely (within 15 minutes per regulatory standards) for 5 of 5 residents interviewed, and 3 of 3 nursing units reviewed. The facility reported a census of 104 residents.

Inspectors wroteBased on facility record review, review of 2567's, and staff interviews, the facility failed to effectively address repeat deficiencies cited during prior surveys, and failed to implement an effective, comprehensive Quality Assurance Performance Improvement (QAPI) program that focused on indicators of the outcomes of care and quality of life. The facility identified a census of 104 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policy review, the facility failed to provide a safe and sanitary environment to help prevent cross contamination and potential exposure to pathogens. The facility failed to follow hand hygiene, change gloves when contaminated, and follow disinfecting practices consistent with accepted standards of practice for 1 of 3 residents reviewed (Resident #8) during a dressing change. The facility staff also failed to transport soiled linens in a manner to prevent cross-contamination for 1 of 3 units observed. The facility reported a census of 104 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review the facility staff failed to transfer a resident as directed by the resident's care plan for one of three residents reviewed for transfers (Resident #4), and failed to transfer a resident appropriately and safely using a gait belt for one of three residents reviewed for transfers (Resident #9). The facility reported a census of 104 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to provide incontinence care in a manner to prevent cross contamination for one of three residents observed for incontinence care (Resident #9), and for one of three residents observed for catheter and nephrostomy care (Resident #10). The facility reported a census of 104 residents.

Inspectors wroteBased on observations, resident, and staff interviews, the facility failed to keep a comfortable temperature in one of the facilites dining rooms. Temperatures were outside the regulation of 71 to 81 degrees. The facility reported a census of 110 residents.

Inspectors wroteBased on facility record review, staff interviews, and facility policy review the facility failed to provide routine bathing per residents wishes for 5 of 5 residents (Resident #1, #86, #33, #59, and #88) reviewed for bathing. The facility reported a census of 110 residents:

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to repair their roof after damage was caused from the Derecho (August 10, 2020). The facility has received multiple bids for a new roof once damage was identified without accepting offers. Observations of damage to the building have caused the ceiling of the activity room to fall, the main dining room to have wet ceiling tiles and the nurses station to bow. A strong, musty, damp odor was smelled throughout the facility. Dried water marks were identified throughout the facility walls. Throughout the 100 and 200 hallways and resident room areas the air vents, ceiling tiles, drop ceiling frame, fire sprinkler system, air conditioner unit duct work and cupboards, a black substance had been identified. The facility reported a census of 110 residents.

Inspectors wroteBased on observations, resident and staff interview, and facility policy review, the facility failed to serve all foods at palatable temperatures for 1 of 3 meal services observed. The facility reported a census of 110 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to have an effective antibiotic stewardship program to monitor infections in the facility and use of antibiotics. The facility reported a census of 110 residents.

Inspectors wroteBased on clinical record review, facility record review, staff, resident and volunteer interviews and review of facility policy, the facility failed to provide care for 2 of 26 residents reviewed (Resident #7 and #19) in a manner to promote dignity and respect. The facility reported a census of 110 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to accurately document advance directives for 1 of 7 residents (Resident #108) reviewed. The facility reported a census of 110 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to develop a comprehensive care plan for one of twenty-six residents reviewed (Resident #11). The facility reported a census of 110 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to revise a Care Plan for 1 of 2 residents reviewed (Residents #55) with a catheter. The facility reported a census of 110 residents.

Inspectors wroteBased on observations, clinical record review, staff and resident interviews, and facility policy review the facility failed to provide the appropriate level of transfer assistance and also failed to stay with the resident while on the toilet as directed by the care plan for 1 of 1 resident reviewed (Resident #19) for toileting transfers. The facility reported a census of 110 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and review of facility policy, the facility failed to provide a restorative program to residents with mobility and range of motion concerns for 2 of 2 residents reviewed (Resident #6 and #7). The facility reported a census of 110 residents

Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to ensure complete and appropriate incontinence care provided for three of four residents observed for incontinence care (Resident #11, #18, and #19). The facility reported a census of 110 residents.

Inspectors wroteBased on clinical record review, facility policy review and resident and staff interviews the facility failed to provide sufficient staff to meet the needs for 1 of 5 residents reviewed (Resident #7) for call lights. The facility reported a census of 110 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews the facility failed to complete Monthly Medication Regimen Review (MRR) by a licensed pharmacist for 3 of 5 residents reviewed (Resident #1, #11, and #14). The facility reported a census of 110.

Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow hand hygiene, gloving and disinfecting practices consistent with accepted standards of practice for 5 of 5 residents reviewed (Resident #55, #65, #18, #45, and #11) during incontinence and catheter care. The facility failed to change gloves when contaminated while providing incontinence cares for 3 of 4 residents observed for cares (Resident #11, #18, and #19). The facility failed to disinfect the floor in a resident's room after contaminated with a soiled washcloth used during resident cares. The facility failed to sanitize hands before, during and after resident cares. [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to ensure 2 of 5 residents (Resident #78 and 34) received education on the influenza vaccination prior to refusal. The facility reported a census of 110 residents.

Inspectors wroteBased on staff interviews and facility policy review the facility failed to ensure a qualified individual serves as the Infection Preventionist (IP). The facility reported a census of 110 residents.