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Deficiency Records for Bishop Rehabilitation and Nursing Center
A list of the most recent deficiencies for Bishop Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Bishop Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2024-07-11 | 2024-09-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-11 | 2024-09-25 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2024-07-11 | 2024-09-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-07-11 | 2024-09-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-11 | 2024-09-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-11 | 2024-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-11 | 2024-09-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-11 | 2024-09-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-07-11 | 2024-09-04 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-07-11 | 2024-09-04 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-07-11 | 2024-09-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-11 | 2024-09-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-07-11 | 2024-09-04 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-07-11 | 2024-09-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-07-11 | 2024-09-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-07-11 | 2024-09-04 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-07-11 | 2024-09-04 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2024-07-11 | 2024-09-04 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-07-11 | 2024-09-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-11 | 2024-09-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-07-11 | 2024-09-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-11 | 2024-09-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-11 | 2024-09-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-11 | 2024-09-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-11 | 2024-09-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-11 | 2024-09-04 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-11 | 2024-09-04 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-07-11 | 2024-09-04 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-07-11 | 2024-09-04 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-07-11 | 2024-09-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-07-11 | 2024-09-04 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-07-11 | 2024-09-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-05 | 2024-05-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-05 | 2024-05-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-05 | 2024-05-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-05 | 2024-05-13 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-12-05 | 2024-05-13 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-01-19 | 2024-02-16 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-05 | 2024-02-02 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-05 | 2024-02-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-05 | 2024-02-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-05 | 2024-02-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-12-05 | 2024-02-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-05 | 2024-02-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-05 | 2024-02-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-05 | 2024-02-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-05 | 2024-02-02 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-12-05 | 2024-02-02 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-05 | 2024-02-02 | N |
| Use approved construction type or materials. | Fire Safety | 2023-12-05 | 2024-01-26 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2023-12-05 | 2024-01-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-05 | 2024-01-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-10-13 | 2023-11-22 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-24 | 2023-08-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-28 | 2023-07-24 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-24 | 2023-07-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-24 | 2023-07-19 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-24 | 2023-07-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-24 | 2023-07-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-24 | 2023-07-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-24 | 2023-07-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-24 | 2023-07-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-24 | 2023-07-19 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-24 | 2023-07-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-24 | 2023-07-19 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-05-24 | 2023-07-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-24 | 2023-07-19 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-05-24 | 2023-07-19 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-05-24 | 2023-07-19 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-24 | 2023-07-19 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-24 | 2023-07-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-24 | 2023-07-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-24 | 2023-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-24 | 2023-07-19 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-24 | 2023-07-19 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-24 | 2023-07-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-05 | 2023-03-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-05 | 2023-03-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-05 | 2023-03-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-19 | 2023-02-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-19 | 2023-02-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-19 | 2023-02-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-19 | 2023-02-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-02-07 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-19 | 2023-02-07 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-02 | 2023-01-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-02 | 2022-12-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-02 | 2022-12-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-02 | 2022-12-17 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-11-02 | 2022-12-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-02 | 2022-12-17 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-02 | 2022-12-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-07 | 2022-10-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-07 | 2022-10-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-07 | 2022-10-10 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-09-07 | 2022-10-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-07 | 2022-10-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-07 | 2022-09-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-04 | 2022-06-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-04 | 2022-06-15 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-05-04 | 2022-06-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-04 | 2022-06-15 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-05-04 | 2022-06-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-04 | 2022-06-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-04 | 2022-06-15 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-05-04 | 2022-06-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-04 | 2022-06-15 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-04 | 2022-06-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-05-04 | 2022-06-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-05-04 | 2022-06-15 | Y |
| Keep all essential equipment working safely. | Health | 2021-12-15 | 2022-01-31 | Y |
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