Map showing the location of Bishop Drumm Retirement Center in Johnston, Iowa
5837 Winwood Drive, Johnston, IA, 50131

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • IowaAbove only 21% of peers388 rated homes · average 3.1★
  • Polk CountyAbove only 25% of peers29 rated homes · average 3.1★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.9 vs IA avg
  • StaffingCan add or remove a star4★+0.5 vs IA avg
  • Quality measuresCan add or remove a star5★+1.6 vs IA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersIA avg2.9★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 43% of peersIA avg3.5★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 78% of peersIA avg3.4★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.65hrsAbove only 46% of peersIA avg3.83Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.82hrsAbove 69% of peersIA avg0.73Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better40%Above 58% of peersIA avg44%RN turnover55%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$339,258Above only 1% of peersIA avg$21,037Fines · denials5 · 4
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
67citations
13inspection dates
6actual harm (G–I)
3immediate jeopardy (J–L)
Sep 17, 2025most recent

Citations by monthJun 2023 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 17, 20258 citationsCycle 1worst G · actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 16, 2025
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Oct 16, 2025
  3. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Oct 16, 2025
  4. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Oct 16, 2025
  5. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesD · isolatedCorrected Oct 16, 2025
  6. F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationF · widespreadCorrected Oct 16, 2025
  7. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 16, 2025
  8. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Oct 16, 2025
Jul 21, 20259 citationsCycle 1worst G · actual harm$195,520, payment denial
  1. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jul 30, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 30, 2025
  3. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesD · isolatedCorrected Jul 30, 2025
  4. F584Honor 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.Resident RightsD · isolatedCorrected Jul 30, 2025
  5. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jul 30, 2025
  6. F578Honor 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.Resident RightsD · isolatedCorrected Jul 30, 2025
  7. F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsD · isolatedCorrected Jul 30, 2025
  8. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jul 30, 2025
  9. F688Provide 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.Quality of Life and CareG · isolatedCorrected Jul 30, 2025
May 29, 20252 citationsCycle 1worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 11, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jun 11, 2025
Apr 3, 20254 citationsCycle 1worst G · actual harmpayment denial
  1. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Apr 22, 2025
  2. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalD · isolatedCorrected Apr 22, 2025
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Jun 11, 2025
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jun 11, 2025
Sep 19, 20244 citationsCycle 2worst G · actual harm$22,588
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 9, 2024
  2. F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsE · patternCorrected Oct 9, 2024
  3. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Oct 9, 2024
  4. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Oct 9, 2024
Aug 18, 20241 citationCycle 2worst J · immediate jeopardy
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareJ · isolatedCorrected Sep 4, 2024
Jun 27, 20243 citationsCycle 2worst G · actual harm$55,424, payment denial
  1. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesF · widespreadCorrected Jul 24, 2024
  2. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationE · patternCorrected Jul 24, 2024
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Sep 4, 2024
May 3, 20243 citationsCycle 2worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected May 17, 2024
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 17, 2024
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 17, 2024
Feb 27, 20246 citationsCycle 2worst J · immediate jeopardy$53,077
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Mar 20, 2024
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareJ · isolatedCorrected Mar 20, 2024
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 20, 2024
  4. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Mar 20, 2024
  5. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 20, 2024
  6. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Mar 20, 2024
Jan 10, 20241 citationCycle 3worst E · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Jan 18, 2024
Oct 9, 20235 citationsCycle 3worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 9, 2023
  2. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationE · patternCorrected Oct 25, 2023
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 25, 2023
  4. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Oct 9, 2023
  5. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Oct 25, 2023
Aug 8, 20234 citationsCycle 3worst J · immediate jeopardy
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Aug 23, 2023
  2. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Oct 25, 2023
  3. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceJ · isolatedCorrected Aug 23, 2023
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 23, 2023
Jun 29, 202317 citationsCycle 3worst E · no actual harmpayment denial, $12,649
  1. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jul 29, 2023
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Jul 29, 2023
  3. F688Provide 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.Quality of Life and CareD · isolatedCorrected Jul 29, 2023
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Oct 25, 2023
  5. F881Implement a program that monitors antibiotic use.Infection ControlE · patternCorrected Jul 29, 2023
  6. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 29, 2023
  7. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jul 29, 2023
  8. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesD · isolatedCorrected Oct 25, 2023
  9. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 23, 2023
  10. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jul 29, 2023
  11. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Aug 23, 2023
  12. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Jul 29, 2023
  13. F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlC · widespreadCorrected Jul 29, 2023
  14. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Jul 29, 2023
  15. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jul 29, 2023
  16. F578Honor 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.Resident RightsD · isolatedCorrected Jul 29, 2023
  17. F584Honor 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.Resident RightsE · patternCorrected Jul 29, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.65hrsAbove only 46% of peers−0.18 vs IA avg
  • Registered nursesRN hours only0.82hrsAbove 69% of peers+0.09 vs IA avg
  • Licensed practical nursesLPN hours0.34hrs
  • Nurse aidesCNA hours2.49hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.22hrs
  • Iowa average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better40%Above 58% of peersIA avg 44%
  • RN turnoverRegistered nurses only55%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy150 certified beds · ~117 residents a day78%Above only 35% of peersIA avg 81%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $339,258In fines
  • 5Fines
  • 4Payment denials
  • $21,037IA avg in fines
Above only 1% of peersFewer fines than 1% of rated homes in Iowa

Actions on record

  1. Jul 21, 2025Civil money penalty$195,520
  2. Jul 21, 2025Denial of payment for new admissionsfrom Aug 9, 2025
  3. Apr 3, 2025Denial of payment for new admissionsfrom Apr 29, 2025
  4. Sep 19, 2024Civil money penalty$22,588
  5. Jun 27, 2024Civil money penalty$55,424
  6. Jun 27, 2024Denial of payment for new admissionsfrom Jul 24, 2024
  7. Feb 27, 2024Civil money penalty$53,077
  8. Jun 29, 2023Denial of payment for new admissionsfrom Sep 7, 2023
  9. Jun 29, 2023Civil money penalty$12,649

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Church related
Chain
Commonspirit Health19 facilities in the chain2.9★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Sylvania Franciscan Health
Indirect owners (5%+)
  • Commonspirit Health
Operational or managerial control
  • Commonspirit Health
  • Concept Rehab, INC.
  • Forvis Mazars LLP
  • Ohio Newspapers, INC.
  • Reliant Care Pharmacy Services LLC
  • The Northern Trust Company
  • Ulrichpinciotti Design Group, LLC
  • Brenda Ballard
  • +24 more
Corporate directors
  • Caitlin Cecil
  • Christina Finn
  • Stacey Grubbs
  • Ted Hazard
  • Kyle Munroe
  • Shelly Murriel
  • Jennifer Nagel
  • Barbara Snodgrass
  • +1 more
Corporate officers
  • Alisa Iffland
  • Prentice Lipsey
  • Heather Rehmer

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 165448 · 5837 Winwood Drive, Johnston, IA, 50131.
  • Percentiles compare this facility with every rated nursing home in Iowa and Polk County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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