Bishop Drumm Retirement Center

F 0684 On 5/28/25 at 11:56 am, the Director of Nursing (DON) stated Resident #2 is followed by the Residency group of one of the local hospitals. She stated the facility's Medical Director overall is able to prescribe Level of Harm - Minimal harm or medications or treatments for any of the facility residents but he does not follow Resident #2 for her normal potential for actual harm visits. She stated she would expect the staff to notify a medical provider anytime a resident's blood sugar is greater than 400 but some staff may do so when it's more like 350. She stated she reviewed the progress Residents Affected - Few notes and agreed there was no notification made to a provider prior to 4/17/25.

On 5/28/25 at 1:40 pm, the Medical Director stated that Resident #2 is followed by the Hospital Residency Group but if staff can either not get ahold of that group or has further concerns, they can always reach out to him as well. He stated if there is a concern for the safety of any resident, he would want the staff to call himself or whoever is on call for him. He stated in this case, he would have reached out to the Residency Group himself and gotten the resident taken care of.

On 5/29/24 the DON stated the facility will be reaching out to their medical providers regarding obtaining parameters of when the providers wish to be notified of changes in vital signs or blood sugars. She stated

they will be updating their education for their nursing staff and using a change of condition form within the electronic health charting. She also stated they would be speaking to the providers about obtaining orders for sliding scale insulin for Resident #2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 8 165448 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165448 B. Wing 05/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Drumm Retirement Center 5837 Winwood Drive Johnston, IA 50131

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 e. Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of

the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day Level of Harm - Minimal harm or look-back period. potential for actual harm Point 6: Interventions to improve or minimize a resident ' s functional abilities will be in accordance with the Residents Affected - Few resident's assessed needs, preferences, stated goals and recognized standards of practice.

Point 7: The resident ' s response to interventions will be monitored, evaluated and revised as appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 165448