Bishop Drumm Retirement Center
5837 Winwood Drive, Johnston, IA 50131
Bishop Drumm Retirement Center is a nursing home in Johnston, Iowa. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (515) 270-1100
- Last standard health inspection
- July 21, 2025 (1 year ago)
- Certified beds
- 150
- Residents per day, on average
- 119.8
- Ownership type
- Non profit - Church related
- Legal business name
- Chi Living Communities
- Chain
- Commonspirit Health
- Takes part in
- Medicare and Medicaid
More health citations than the Iowa average (80 vs 21).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
1 citation
Health inspection on August 13, 2026
CMS lists this as a complaint inspection.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS has cited this home for F0725 8 times since 2023.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
6 citations
Health inspection on June 11, 2026
CMS lists this as a complaint inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on July 1, 2026.
CMS has cited this home for F0580 3 times since 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 1, 2026.
CMS has cited this home for F0684 6 times since 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 1, 2026.
CMS has cited this home for F0689 7 times since 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 1, 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on July 1, 2026.
CMS has cited this home for F0842 4 times since 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 1, 2026.
CMS has cited this home for F0880 8 times since 2023.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Fine
CMS changed the fine from July 21, 2025 from $195,520 to $127,088.
CMS update of February 25, 2026
Fire safety citation
CMS changed citation K0324 from severity F to E. It is from the fire safety inspection on June 29, 2023. Severity E: potential for more than minimal harm, pattern.
10 citations
Health inspection on February 18, 2026
CMS lists this as a complaint inspection.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on April 20, 2026.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on April 20, 2026.
Citation F0865. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a plan that describes the process for conducting QAPI and QAA activities.
CMS lists it as corrected on April 20, 2026.
CMS has cited this home for F0865 2 times since 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 20, 2026.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on April 20, 2026.
CMS has cited this home for F0550 4 times since 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on April 20, 2026.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 20, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 20, 2026.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on April 20, 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on April 20, 2026.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Fire safety citation
CMS changed citation K0324 from severity E to F. It is from the fire safety inspection on June 28, 2023. Severity F: potential for more than minimal harm, widespread.
8 citations
Health inspection on September 17, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
73 of 387 Iowa homes (19%) got a citation at the actual harm level in 2025.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0686 4 times since 2024.
Citation F0865. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a plan that describes the process for conducting QAPI and QAA activities.
CMS lists it as corrected on October 16, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on October 16, 2025.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0658 3 times since 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0690 3 times since 2023.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 16, 2025.
Citation F0725. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on October 16, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 16, 2025.
Payment stopped
August 9, 2025 (1 year ago)
CMS stopped payment for new admissions from August 9, 2025, for 68 days.
CMS update of July 30, 2025
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
9 citations
Health inspection on July 21, 2025
CMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
73 of 387 Iowa homes (19%) got a citation at the actual harm level in 2025.
Citation F0688. Severity G: actual harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 30, 2025.
CMS has cited this home for F0688 2 times since 2023.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 30, 2025.
CMS has cited this home for F0578 2 times since 2023.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 30, 2025.
CMS has cited this home for F0584 2 times since 2023.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on July 30, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 30, 2025.
CMS has cited this home for F0656 3 times since 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 30, 2025.
CMS has cited this home for F0657 2 times since 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 30, 2025.
Citation F0725. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on July 30, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 30, 2025.
8 citations
Fire safety inspection on July 21, 2025
CMS lists this as a standard inspection.
Citation K0351. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on July 28, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 28, 2025.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on July 28, 2025.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on July 25, 2025.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on July 28, 2025.
CMS has cited this home for K0291 2 times since 2023.
Citation K0362. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on July 28, 2025.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on July 28, 2025.
CMS has cited this home for K0363 2 times since 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on July 25, 2025.
Fine
July 21, 2025 (1 year ago)
CMS fine of $127,088 on July 21, 2025.
CMS update of June 25, 2025
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Fine
CMS changed the fine from September 19, 2024 from $34,750 to $22,588.
2 citations
Health inspection on May 29, 2025
CMS lists this as a complaint inspection.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 11, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 11, 2025.
Payment stopped
April 29, 2025 (1 year ago)
CMS stopped payment for new admissions from April 29, 2025, for 43 days.
4 citations
Health inspection on April 3, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
73 of 387 Iowa homes (19%) got a citation at the actual harm level in 2025.
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 11, 2025.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 11, 2025.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on April 22, 2025.
Citation F0925. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on April 22, 2025.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Fine
CMS changed the fine from February 27, 2024 from $52,127 to $53,077.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
4 citations
Health inspection on September 19, 2024
CMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
91 of 387 Iowa homes (24%) got a citation at the actual harm level in 2024.
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on October 9, 2024.
Citation F0557. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS lists it as corrected on October 9, 2024.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on October 9, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 9, 2024.
2 citations
Fire safety inspection on September 19, 2024
CMS lists this as a standard inspection.
Citation K0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that testing and maintenance of electrical equipment is performed.
CMS lists it as corrected on October 11, 2024.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on September 25, 2024.
CMS has cited this home for K0923 2 times since 2023.
Fine
September 19, 2024 (2 years ago)
CMS fine of $22,588 on September 19, 2024.
1 citation
Health inspection on August 18, 2024
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
57 of 387 Iowa homes (15%) got a citation at the immediate jeopardy level in 2024.
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on September 4, 2024.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Payment stopped
July 24, 2024 (2 years ago)
CMS stopped payment for new admissions from July 24, 2024, for 42 days.
3 citations
Health inspection on June 27, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
91 of 387 Iowa homes (24%) got a citation at the actual harm level in 2024.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on September 4, 2024.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on July 24, 2024.
Citation F0835. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on July 24, 2024.
Fine
June 27, 2024 (2 years ago)
CMS fine of $55,424 on June 27, 2024.
3 citations
Health inspection on May 3, 2024
CMS lists this as a complaint inspection.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on May 17, 2024.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on May 17, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 17, 2024.
CMS has cited this home for F0677 2 times since 2023.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of February 29, 2024
Ownership
CMS lists this home under a new chain.
6 citations
Health inspection on February 27, 2024
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
57 of 387 Iowa homes (15%) got a citation at the immediate jeopardy level in 2024.
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on March 20, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 20, 2024.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on March 20, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 20, 2024.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on March 20, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 20, 2024.
Fine
February 27, 2024 (2 years ago)
CMS fine of $53,077 on February 27, 2024.
1 citation
Health inspection on January 10, 2024
CMS lists this as a complaint inspection.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on January 18, 2024.
CMS update of December 21, 2023
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
5 citations
Health inspection on October 9, 2023
CMS lists this as a complaint inspection.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on October 25, 2023.
Citation F0867. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on October 25, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 9, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 25, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on October 9, 2023.
17 citations
Health inspection on June 29, 2023
CMS lists this as a standard inspection.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 29, 2023.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on July 29, 2023.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 25, 2023.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on July 29, 2023.
Citation F0881. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on July 29, 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on July 29, 2023.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 29, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 29, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 29, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 29, 2023.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 29, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on August 23, 2023.
Citation F0725. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on October 25, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on July 29, 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 23, 2023.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on July 29, 2023.
Citation F0882. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on July 29, 2023.
7 citations
Fire safety inspection on June 29, 2023
CMS lists this as a standard inspection.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on July 11, 2023.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on July 11, 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 29, 2023.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on August 31, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on July 11, 2023.
Citation K0911. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on July 11, 2023.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on July 14, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- SYLVANIA FRANCISCAN HEALTH5% or greater direct ownership interest · 100% · since 07/01/2016
- COMMONSPIRIT HEALTH5% or greater indirect ownership interest · 100% · since 07/01/2016
- COMMONSPIRIT HEALTHOperational/managerial control · not applicable · since 07/01/2016
- CONCEPT REHAB, INC.Operational/managerial control · not applicable · since 07/01/2016
- FORVIS MAZARS LLPOperational/managerial control · not applicable · since 08/16/2019
- OHIO NEWSPAPERS, INC.Operational/managerial control · not applicable · since 07/01/2011
- RELIANT CARE PHARMACY SERVICES LLCOperational/managerial control · not applicable · since 02/01/2024
- THE NORTHERN TRUST COMPANYOperational/managerial control · not applicable · since 07/01/2016
- ULRICHPINCIOTTI DESIGN GROUP, LLCOperational/managerial control · not applicable · since 07/01/2011
- BALLARD, BRENDAOperational/managerial control · not applicable · since 07/01/2016
- BOYSEN, CAREYOperational/managerial control · not applicable · since 07/01/2016
- BRADEN, ADAMOperational/managerial control · not applicable · since 11/24/2019
- CECIL, CAITLINOperational/managerial control · not applicable · since 07/01/2016
- FAZIO, CHRISTOPHEROperational/managerial control · not applicable · since 01/09/2024
- FINN, CHRISTINAOperational/managerial control · not applicable · since 07/01/2016
- GRUBBS, STACEYOperational/managerial control · not applicable · since 07/01/2016
- HANSON, SCOTTOperational/managerial control · not applicable · since 07/01/2016
- HAZARD, TEDOperational/managerial control · not applicable · since 07/01/2016
- HERRERA, ANGELAOperational/managerial control · not applicable · since 10/02/2024
- HOWARD, CASEYOperational/managerial control · not applicable · since 07/01/2016
- IFFLAND, ALISAOperational/managerial control · not applicable · since 07/01/2016
- KELLER, MICHAELAOperational/managerial control · not applicable · since 02/08/2020
- LANG, TRESTINOperational/managerial control · not applicable · since 10/15/2024
- LONGHIN-HOWARD, JOANOperational/managerial control · not applicable · since 07/01/2016
- MCFARLAND, DIANNEOperational/managerial control · not applicable · since 12/18/2023
- MILLER, LORIOperational/managerial control · not applicable · since 07/01/2016
- MUNROE, KYLEOperational/managerial control · not applicable · since 07/01/2016
- MURRIEL, SHELLYOperational/managerial control · not applicable · since 07/01/2016
- NAGEL, JENNIFEROperational/managerial control · not applicable · since 07/01/2016
- NASET-PAYNE, JANETOperational/managerial control · not applicable · since 02/24/2025
- REBIK, MARYOperational/managerial control · not applicable · since 04/10/2018
- REHMER, HEATHEROperational/managerial control · not applicable · since 06/05/2024
- TROSEN, RYANOperational/managerial control · not applicable · since 09/26/2024
- WINE, MATTHEWOperational/managerial control · not applicable · since 07/01/2016
Questions
When was Bishop Drumm Retirement Center last inspected?
CMS lists July 21, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Bishop Drumm Retirement Center have?
CMS lists 80 health citations since June 29, 2023. CMS also calls these deficiencies.
Has Bishop Drumm Retirement Center been fined?
CMS lists 4 fines in the past three years, $258,177 in total.
What is the CMS star rating of Bishop Drumm Retirement Center?
Its CMS overall star rating is 1 of 5.
Is Bishop Drumm Retirement Center a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.