23 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Johnston, IA
2-star overall rating with 1-star inspections with Special Focus status with $339,258 in total fines with 23 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
5837 Winwood Drive, Johnston, IA
(515) 270-1100
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
150
Certified beds
Average residents
117
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
2002-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.82
Registered nurse staffing
LPN hours / resident day
0.34
Licensed practical nurse staffing
Aide hours / resident day
2.49
Nurse aide staffing
Weekend hours
3.22
Weekend nurse staffing
RN turnover
55%
Annual RN turnover
Total nurse turnover
40%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
94.0%
2.8 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.2% |
95.2%
6 pts worse
|
95.5%
6.3 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.7%
0.7 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
4.0%
2.4 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 10.9% |
4.9%
6 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.1% |
20.6%
4.5 pts better
|
19.6%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
19.8%
10.4 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.3% |
18.5%
7.2 pts better
|
16.3%
5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.5% |
18.3%
10.8 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.7%
0.8 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.5%
1.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.7% |
26.0%
7.7 pts worse
|
19.8%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.3%
1.7 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.2% |
84.3%
4.9 pts better
|
81.7%
7.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
13.1%
3.1 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.9%
0.8 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.1% |
73.3%
10.8 pts better
|
79.7%
4.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
21.3%
7.1 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (9 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (10 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-07-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-28
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-28
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-25
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-07-28
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-07-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-25
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-10-11
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-25
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-11
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-11
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-29
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-11
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-07-11
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-14
Inspection history
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-16
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-10-16
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-10-16
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-16
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-16
Health
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.
Corrected 2025-10-16
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-10-16
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-16
Health
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.
Corrected 2025-07-30
Health
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.
Corrected 2025-07-30
Health
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.
Corrected 2025-07-30
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-30
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-30
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-07-30
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-11
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-22
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-04-22
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-09
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-10-09
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-09
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-09
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-04
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-04
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-07-24
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-24
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-17
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-20
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-20
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-20
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-18
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-25
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-25
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-25
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-09
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-23
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-23
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-23
Health
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.
Corrected 2023-07-29
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-25
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-29
Health
Implement a program that monitors antibiotic use.
Corrected 2023-07-29
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-29
Health
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.
Corrected 2023-07-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-29
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-29
Health
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.
Corrected 2023-07-29
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-23
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-25
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-29
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-23
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-29
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-07-29
Penalties and ownership
Fine · fine $195,520
Fine
Payment Denial · denial start 2025-08-09 · 68 days
68 day denial
Payment Denial · denial start 2025-04-29 · 43 days
43 day denial
Fine · fine $22,588
Fine
Fine · fine $55,424
Fine
Payment Denial · denial start 2024-07-24 · 42 days
42 day denial
Fine · fine $53,077
Fine
Fine · fine $12,649
Fine
Payment Denial · denial start 2023-09-07 · 48 days
48 day denial
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
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Corporate Director · Individual
Operational/Managerial Control · Organization
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Corporate Director · Individual
Nearby options
Johnston, IA
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Urbandale, IA
1-star overall rating with 1-star inspections with $122,691 in total fines with 15 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
Johnston, IA
5-star overall rating with 4-star inspections with $6,923 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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