Starfile

Starfile / Iowa

Bishop Drumm Retirement Center

5837 Winwood Drive, Johnston, IA 50131 · CCN 165448

SFF Candidate

Ratings

Overall
★★☆☆☆ 2
Health inspection
★☆☆☆☆ 1
Quality measures
★★★★★ 5
Staffing
★★★★☆ 4

Facility

Ownership type
Non profit - Church related
Certified beds
150
Avg residents/day
116.8
Phone
5152701100

Inspection history vs Iowa & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

CycleInspection dateThis facilityIowa avgNational avgvs state
12025-07-21236.29.5+16.8 worse
22024-09-19117.09.8+4.0 worse
32023-06-29337.99.3+25.1 worse

Cycle 1 deficiencies by category

CategoryDeficiencies
Quality of life and care9
Resident assessment and care planning3
Nursing and physician services3
Resident rights4
Environmental1
Administration1
Infection control2

Staffing (hours per resident per day)

MetricThis facilityTurnover
Total nurse staffing (reported)3.6540.0%
RN staffing (reported)0.8255.2%
Total nurse staffing (adjusted)3.82

Fines & penalties

Total fines
$339,258
Number of fines
5
Number of penalties
9
Payment denials
4

Chain

Chain
COMMONSPIRIT HEALTH
Facilities in chain
19
Chain avg overall
2.90 / 5

Inspection citations (67)3 immediate jeopardy6 actual harm

  1. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-09-17 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  2. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2025-09-17 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  3. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-09-17 · Health · corrected 2025-10-16

    Actual harm

  4. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2025-09-17 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  5. DF0693Ensure 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.2025-09-17 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  6. DF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2025-09-17 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  7. FF0865Have a plan that describes the process for conducting QAPI and QAA activities.2025-09-17 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  8. DF0880Provide and implement an infection prevention and control program.2025-09-17 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  9. DF0578Honor 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.2025-07-21 · Health · corrected 2025-07-30

    Potential for more than minimal harm

  10. DF0584Honor 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.2025-07-21 · Health · corrected 2025-07-30

    Potential for more than minimal harm

  11. DF0628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.2025-07-21 · Health · corrected 2025-07-30

    Potential for more than minimal harm

  12. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-07-21 · Health · corrected 2025-07-30

    Potential for more than minimal harm

  13. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-07-21 · Health · corrected 2025-07-30

    Potential for more than minimal harm

  14. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-07-21 · Health · corrected 2025-07-30

    Potential for more than minimal harm

  15. GF0688Provide 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.2025-07-21 · Health · corrected 2025-07-30

    Actual harm

  16. DF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2025-07-21 · Health · corrected 2025-07-30

    Potential for more than minimal harm

  17. DF0880Provide and implement an infection prevention and control program.2025-07-21 · Health · corrected 2025-07-30

    Potential for more than minimal harm

  18. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-05-29 · Health · corrected 2025-06-11

    Potential for more than minimal harm

  19. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-05-29 · Health · corrected 2025-06-11

    Potential for more than minimal harm

  20. GF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-04-03 · Health · corrected 2025-06-11

    Actual harm

  21. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-04-03 · Health · corrected 2025-06-11

    Actual harm

  22. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2025-04-03 · Health · corrected 2025-04-22

    Potential for more than minimal harm

  23. DF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2025-04-03 · Health · corrected 2025-04-22

    Potential for more than minimal harm

  24. EF0557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.2024-09-19 · Health · corrected 2024-10-09

    Potential for more than minimal harm

  25. GF0692Provide enough food/fluids to maintain a resident's health.2024-09-19 · Health · corrected 2024-10-09

    Actual harm

  26. EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-09-19 · Health · corrected 2024-10-09

    Potential for more than minimal harm

  27. EF0880Provide and implement an infection prevention and control program.2024-09-19 · Health · corrected 2024-10-09

    Potential for more than minimal harm

  28. JF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-08-18 · Health · corrected 2024-09-04

    Immediate jeopardy

  29. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-06-27 · Health · corrected 2024-09-04

    Actual harm

  30. FF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2024-06-27 · Health · corrected 2024-07-24

    Potential for more than minimal harm

  31. EF0835Administer the facility in a manner that enables it to use its resources effectively and efficiently.2024-06-27 · Health · corrected 2024-07-24

    Potential for more than minimal harm

  32. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-05-03 · Health · corrected 2024-05-17

    Potential for more than minimal harm

  33. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2024-05-03 · Health · corrected 2024-05-17

    Potential for more than minimal harm

  34. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-05-03 · Health · corrected 2024-05-17

    Potential for more than minimal harm

  35. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-02-27 · Health · corrected 2024-03-20

    Potential for more than minimal harm

  36. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2024-02-27 · Health · corrected 2024-03-20

    Potential for more than minimal harm

  37. JF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-02-27 · Health · corrected 2024-03-20

    Immediate jeopardy

  38. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-02-27 · Health · corrected 2024-03-20

    Potential for more than minimal harm

  39. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-02-27 · Health · corrected 2024-03-20

    Potential for more than minimal harm

  40. DF0880Provide and implement an infection prevention and control program.2024-02-27 · Health · corrected 2024-03-20

    Potential for more than minimal harm

  41. EF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-01-10 · Health · corrected 2024-01-18

    Potential for more than minimal harm

  42. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-10-09 · Health · corrected 2023-10-25

    Potential for more than minimal harm

  43. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2023-10-09 · Health · corrected 2023-10-09

    Potential for more than minimal harm

  44. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2023-10-09 · Health · corrected 2023-10-25

    Potential for more than minimal harm

  45. EF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2023-10-09 · Health · corrected 2023-10-25

    Potential for more than minimal harm

  46. EF0880Provide and implement an infection prevention and control program.2023-10-09 · Health · corrected 2023-10-09

    Potential for more than minimal harm

  47. EF0658Ensure services provided by the nursing facility meet professional standards of quality.2023-08-08 · Health · corrected 2023-08-23

    Potential for more than minimal harm

  48. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-08-08 · Health · corrected 2023-08-23

    Potential for more than minimal harm

  49. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2023-08-08 · Health · corrected 2023-10-25

    Potential for more than minimal harm

  50. JF0760Ensure that residents are free from significant medication errors.2023-08-08 · Health · corrected 2023-08-23

    Immediate jeopardy

  51. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  52. DF0578Honor 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.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  53. EF0584Honor 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.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  54. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  55. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  56. EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  57. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  58. DF0688Provide 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.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  59. EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-06-29 · Health · corrected 2023-10-25

    Potential for more than minimal harm

  60. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2023-06-29 · Health · corrected 2023-08-23

    Potential for more than minimal harm

  61. DF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2023-06-29 · Health · corrected 2023-10-25

    Potential for more than minimal harm

  62. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  63. EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  64. DF0880Provide and implement an infection prevention and control program.2023-06-29 · Health · corrected 2023-08-23

    Potential for more than minimal harm

  65. EF0881Implement a program that monitors antibiotic use.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

  66. CF0882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.2023-06-29 · Health · corrected 2023-07-29

    Potential for minimal harm

  67. DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2023-06-29 · Health · corrected 2023-07-29

    Potential for more than minimal harm

Ownership

OwnerTypeRolePercentSince
SYLVANIA FRANCISCAN HEALTHOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%2016-07-01
COMMONSPIRIT HEALTHOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%2016-07-01
COMMONSPIRIT HEALTHOrganizationOPERATIONAL/MANAGERIAL CONTROL2016-07-01
CONCEPT REHAB, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL2016-07-01
FORVIS MAZARS LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL2019-08-16
OHIO NEWSPAPERS, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL2011-07-01
RELIANT CARE PHARMACY SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL2024-02-01
THE NORTHERN TRUST COMPANYOrganizationOPERATIONAL/MANAGERIAL CONTROL2016-07-01
ULRICHPINCIOTTI DESIGN GROUP, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL2011-07-01
BALLARD, BRENDAIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
BOYSEN, CAREYIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
BRADEN, ADAMIndividualOPERATIONAL/MANAGERIAL CONTROL2019-11-24
CECIL, CAITLINIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
FAZIO, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL2024-01-09
FINN, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
GRUBBS, STACEYIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
HANSON, SCOTTIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
HAZARD, TEDIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
HERRERA, ANGELAIndividualOPERATIONAL/MANAGERIAL CONTROL2024-10-02
HOWARD, CASEYIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
IFFLAND, ALISAIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
KELLER, MICHAELAIndividualOPERATIONAL/MANAGERIAL CONTROL2020-02-08
LANG, TRESTINIndividualOPERATIONAL/MANAGERIAL CONTROL2024-10-15
LONGHIN-HOWARD, JOANIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
MILLER, LORIIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
MUNROE, KYLEIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
MURRIEL, SHELLYIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
NAGEL, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
NASET-PAYNE, JANETIndividualOPERATIONAL/MANAGERIAL CONTROL2025-02-24
REBIK, MARYIndividualOPERATIONAL/MANAGERIAL CONTROL2018-04-10
REHMER, HEATHERIndividualOPERATIONAL/MANAGERIAL CONTROL2024-06-05
SOUKUP-MCFARLAND, DIANNEIndividualOPERATIONAL/MANAGERIAL CONTROL2023-12-18
TROSEN, RYANIndividualOPERATIONAL/MANAGERIAL CONTROL2024-09-26
WINE, MATTHEWIndividualOPERATIONAL/MANAGERIAL CONTROL2016-07-01
CECIL, CAITLINIndividualCORPORATE DIRECTOR2016-07-01
FINN, CHRISTINAIndividualCORPORATE DIRECTOR2016-07-01
GRUBBS, STACEYIndividualCORPORATE DIRECTOR2016-07-01
HAZARD, TEDIndividualCORPORATE DIRECTOR2016-07-01
MUNROE, KYLEIndividualCORPORATE DIRECTOR2016-07-01
MURRIEL, SHELLYIndividualCORPORATE DIRECTOR2016-07-01
NAGEL, JENNIFERIndividualCORPORATE DIRECTOR2016-07-01
SNODGRASS, BARBARAIndividualCORPORATE DIRECTOR2016-07-01
WINE, MATTHEWIndividualCORPORATE DIRECTOR2016-07-01
IFFLAND, ALISAIndividualCORPORATE OFFICER2016-09-13
LIPSEY, PRENTICEIndividualCORPORATE OFFICER2021-09-17
REHMER, HEATHERIndividualCORPORATE OFFICER2024-06-25

Other facilities in Johnston

NameOverallBeds
Brio of Johnston, LLC★★★★★36
Childserve Habilitation Center★★★★★74

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.