01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-21 | 33 | 2025-07-21 | 8 |
| Cycle 2 | 2024-09-19 | 11 | 2024-09-19 | 2 |
| Cycle 3 | 2023-06-29 | 39 | 2023-06-29 | 7 |
CMS CCN 1654482026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Bishop Drumm Retirement Center
5837 Winwood Drive · Johnston, IA 50131 · Polk County
Certified beds150CMS provider file
Recent citation rows100current CMS citation release
Penalty rows7current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
100 rows in the current release
9 rows carry G–L scope/severity codes; 3 carry J–L. 21 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-11 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has no plan of correction · complaint2026-06-11 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has no plan of correction · complaint2026-06-11 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has no plan of correction · complaint2026-06-11 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has no plan of correction · complaint2026-06-11 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has no plan of correction · complaint2026-06-11 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has no plan of correction · complaint2026-02-18 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2026-04-20 · complaint2026-02-18 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2026-04-20 · complaint2026-02-18 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-04-20 · complaint2026-02-18 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-04-20 · complaint2026-02-18 · HEALTHF0725Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2026-04-20 · complaint2026-02-18 · HEALTHF0727Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Correction field: Deficient, Provider has date of correction · 2026-04-20 · complaint2026-02-18 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2026-04-20 · complaint2026-02-18 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2026-04-20 · complaint2026-02-18 · HEALTHF0865Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Correction field: Deficient, Provider has date of correction · 2026-04-20 · complaint2026-02-18 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-04-20 · complaint2025-09-17 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-10-16 · complaint2025-09-17 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-10-16 · complaint2025-09-17 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-10-16 · complaint2025-09-17 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-10-16 · complaint2025-09-17 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-16 · complaint2025-09-17 · HEALTHF0725Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2025-10-16 · complaint2025-09-17 · HEALTHF0865Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Correction field: Deficient, Provider has date of correction · 2025-10-16 · complaint2025-09-17 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-16 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-07-21 | Fine | $127,088 | 0 |
| 2025-07-21 | Payment Denial | $0 | 68 |
| 2025-04-03 | Payment Denial | $0 | 43 |
| 2024-09-19 | Fine | $22,588 | 0 |
| 2024-06-27 | Fine | $55,424 | 0 |
| 2024-06-27 | Payment Denial | $0 | 42 |
| 2024-02-27 | Fine | $53,077 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- SYLVANIA FRANCISCAN HEALTHOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/2016
- COMMONSPIRIT HEALTHOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 07/01/2016
- LIPSEY, PRENTICEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 09/17/2021
- MBANU, TERIKAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/05/2024
- MELFI, MITCHIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/01/2016
- CECIL, CAITLINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2016
- FINN, CHRISTINAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2016
- GRUBBS, STACEYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2016
- HAZARD, TEDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2016
- MUNROE, KYLEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2016
- MURRIEL, SHELLYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2016
- NAGEL, JENNIFERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2016
- SNODGRASS, BARBARAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2016
- WINE, MATTHEWIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2016
- IFFLAND, ALISAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/13/2016
- LIPSEY, PRENTICEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/17/2021
- REHMER, HEATHERIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/25/2024
- COMMONSPIRIT HEALTHOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2016
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.64per resident day
RN hours0.81per resident day
Weekend nurse hours3.18per resident day
Staff turnover34.9%CMS reported field
06 / LOCAL RECORDS
Open the Johnston ledger →