Inspection visit
Inspection
Citations
17 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F688 - Mobility
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.
- 0291GeneralS&S Dpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0293GeneralS&S Epotential for harm
Have properly located and lighted "Exit" signs.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F584 - Safe Environment
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.
F628 - Documentation
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0362GeneralS&S Dpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the July 21, 2025 survey of Bishop Drumm Retirement Center?
This was a inspection survey of Bishop Drumm Retirement Center on July 21, 2025. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Bishop Drumm Retirement Center on July 21, 2025?
Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, u..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.