Bishop Drumm Retirement Center

F-F686 cited 2/24/21, 2/27/24, and during the current survey.

A Quality Assurance and Performance Improvement (QAPI)) change process implemented 10/24/22 revealed the QAPI as a systematic approach for performance improvement activities to ensure changes are effective and improvements are sustained. Performance improvement is a continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying opportunities for improvement, testing new approaches to fix underlying causes of persistent and systemic problems or barriers to improvement. The QAPI focused on systems and processes, identified system gaps, and identified root causes of concern.

In an interview on 6/27/24 at 2:15 PM, the surveyor asked the Administrator what the facility had done to improve and address the repeat deficiencies from the most recert survey and prior surveys. The Administrator responded he had been the Administrator at this facility since 3/2024, and he couldn't speak for prior Administration. They continued to do audits and staff education monthly since he started in 3/2024.

The Administrator stated he looked at the CASPER report and the areas that affected the facility's 5-Star Rating Scale and chose to work on pressure ulcers due to pressure ulcers had a higher rating. He implemented a PIP (Performance Improvement Plan) on 4/2024, and put in some action plans in the past month. An all staff skills fair held 6/5 -6/7/24 which entailed skin observations, assessments, and other areas of concern. They made a targeted effort and are strategically working with staff to be successful to learn what needs to be done. For staffing and call light response times, they aimed for a 1:15 ratio for staffing but the staffing levels may be missed due to the staff call ins. Nurse managers are on an on-call rotation and expected to come in and fill in when needed. During peak times, it's all hands on deck helping to answer call lights, pass meal trays, and do what is needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 165448

F-F725 cited 6/29/23, 10/9/23, and during the current survey