Cycle 1
Health 2025-07-21 · Fire 2025-07-21
23 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Johnston, IA
Bishop Drumm Retirement Center
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
Facility snapshot
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
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.34
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,069
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.81
Baseline 20.05% · Performance 20.59% · Measure score 1.81 · Achievement 1.81 · Improvement 0
Healthcare-associated infections
0
Baseline 6.64% · Performance 8.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.94
Baseline 42.86% · Performance 43.48% · Measure score 4.94 · Achievement 4.94 · Improvement 0
Adjusted total nurse staffing
1.85
Baseline 3.53 hours · Performance 3.60 hours · Measure score 1.85 · Achievement 1.85 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.52% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 6.96% · Lower 95% interval 6.86% |
| Discharge to community | 60.65% |
50.57%
10.1 pts better
|
Better than the National Rate · Eligible stays 99 · Observed rate 56.57% · Lower 95% interval 51.64% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 50 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 68.42% |
53.69%
14.7 pts better
|
Numerator 26 · Denominator 38 |
| Discharge mobility score | 60.53% |
50.94%
9.6 pts better
|
Numerator 23 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 2 · Denominator 50 · Adjusted rate 3.93% |
| Healthcare-associated infections requiring hospitalization | 8.81% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 12.73% · Lower 95% interval 5.4% |
| Staff COVID-19 vaccination coverage | 6.53% |
8.2%
1.7 pts worse
|
Numerator 13 · Denominator 199 |
| Staff flu vaccination coverage | 38.4% |
42%
3.6 pts worse
|
Numerator 96 · Denominator 250 |
| Discharge function score | 71.05% |
56.45%
14.6 pts better
|
Numerator 27 · Denominator 38 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| 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 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 98.0% · Q4 89.8% · 4Q avg 96.8% |
| 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 · 4Q avg 89.2% |
| 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 · Q1 3.9% · Q2 4.0% · Q3 5.0% · Q4 4.6% · 4Q avg 4.4% · Used in QM five-star |
| 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 · Q1 2.2% · Q2 2.3% · Q3 0.0% · Q4 2.0% · 4Q avg 1.6% |
| 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 · Q1 10.3% · Q2 17.2% · Q3 6.9% · Q4 9.3% · 4Q avg 10.9% |
| 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 · Q1 13.3% · Q2 16.7% · Q3 16.9% · Q4 17.5% · 4Q avg 16.1% |
| 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 · Q1 8.5% · Q2 10.4% · Q3 8.7% · Q4 9.9% · 4Q avg 9.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 20.8% · Q2 11.9% · Q3 9.1% · Q4 4.5% · 4Q avg 11.3% · Used in QM five-star |
| 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 · Q1 15.5% · Q2 7.0% · Q3 7.1% · Q4 1.1% · 4Q avg 7.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.0% · Q3 1.8% · Q4 0.7% · 4Q avg 0.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 0.7% · Used in QM five-star |
| 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 · Q1 23.0% · Q2 33.2% · Q3 34.1% · Q4 43.0% · 4Q avg 33.7% |
| 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 · Q1 2.0% · Q2 1.4% · Q3 3.2% · Q4 3.7% · 4Q avg 2.6% · Used in QM five-star |
| 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 · Q1 94.9% · Q2 98.1% · Q3 87.2% · Q4 72.2% · 4Q avg 89.2% |
| 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 · Adjusted 10.0% · Observed 9.5% · Expected 10.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.9% · Q3 2.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| 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 · 4Q avg 84.1% |
| 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 · Adjusted 28.4% · Observed 28.6% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-19 · Fire 2024-09-19
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-06-29 · Fire 2023-06-29
33 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-07-28
F · Potential for more than minimal harm
2025-07-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-28
E · Potential for more than minimal harm
2025-07-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-28
E · Potential for more than minimal harm
2025-07-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-07-28
D · Potential for more than minimal harm
2025-07-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-07-28
D · Potential for more than minimal harm
2025-07-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-28
D · Potential for more than minimal harm
2025-07-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-25
F · Potential for more than minimal harm
2024-09-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-25
F · Potential for more than minimal harm
2023-06-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-11
F · Potential for more than minimal harm
2023-06-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-29
K321 · Smoke Deficiencies
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
E · Potential for more than minimal harm
2023-06-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-29
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-14
Inspection history
Recent health citations
G · Actual harm
2025-09-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-16
F · Potential for more than minimal harm
2025-09-17
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-10-16
D · Potential for more than minimal harm
2025-09-17
F580 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2025-09-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-16
D · Potential for more than minimal harm
2025-09-17
F690 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2025-09-17
F693 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2025-09-17
F725 · Nursing and Physician Services Deficiencies
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
D · Potential for more than minimal harm
2025-09-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-16
G · Actual harm
2025-07-21
F688 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2025-07-21
F578 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2025-07-21
F584 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2025-07-21
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-21
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2025-07-21
F657 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2025-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-21
F725 · Nursing and Physician Services Deficiencies
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
D · Potential for more than minimal harm
2025-07-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-05-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-11
G · Actual harm
2025-04-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-11
G · Actual harm
2025-04-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-11
E · Potential for more than minimal harm
2025-04-03
F725 · Nursing and Physician Services Deficiencies
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
D · Potential for more than minimal harm
2025-04-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-04-22
G · Actual harm
2024-09-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-09-19
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-09-19
F842 · Resident Assessment and Care Planning Deficiencies
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
E · Potential for more than minimal harm
2024-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-09
J · Immediate jeopardy
2024-08-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-04
G · Actual harm
2024-06-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-06-27
F725 · Nursing and Physician Services Deficiencies
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
E · Potential for more than minimal harm
2024-06-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-17
J · Immediate jeopardy
2024-02-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2024-02-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F842 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2024-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-01-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-18
E · Potential for more than minimal harm
2023-10-09
F725 · Nursing and Physician Services Deficiencies
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
E · Potential for more than minimal harm
2023-10-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-10-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-10-09
F690 · Quality of Life and Care Deficiencies
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
J · Immediate jeopardy
2023-08-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-08-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-08-08
F725 · Nursing and Physician Services Deficiencies
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
D · Potential for more than minimal harm
2023-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-06-29
F584 · Resident Rights Deficiencies
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
E · Potential for more than minimal harm
2023-06-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-06-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-06-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-06-29
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
F578 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2023-06-29
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2023-06-29
F657 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2023-06-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
F688 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2023-06-29
F690 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2023-06-29
F725 · Nursing and Physician Services Deficiencies
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
D · Potential for more than minimal harm
2023-06-29
F756 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2023-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-06-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-29
C · Minimal harm
2023-06-29
F882 · Infection Control Deficiencies
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
What sits behind the stars
$195,520
2025-07-21
Fine
Fine · fine $195,520
Fine
$0
2025-07-21
Payment Denial
Payment Denial · denial start 2025-08-09 · 68 days
68 day denial
$0
2025-04-03
Payment Denial
Payment Denial · denial start 2025-04-29 · 43 days
43 day denial
$22,588
2024-09-19
Fine
Fine · fine $22,588
Fine
$55,424
2024-06-27
Fine
Fine · fine $55,424
Fine
$0
2024-06-27
Payment Denial
Payment Denial · denial start 2024-07-24 · 42 days
42 day denial
$53,077
2024-02-27
Fine
Fine · fine $53,077
Fine
$12,649
2023-06-29
Fine
Fine · fine $12,649
Fine
$0
2023-06-29
Payment Denial
Payment Denial · denial start 2023-09-07 · 48 days
48 day denial
Ownership
Commonspirit Health
5% Or Greater Indirect Ownership Interest · Organization
Sylvania Franciscan Health
5% Or Greater Direct Ownership Interest · Organization
Ballard, Brenda
Operational/Managerial Control · Individual
Boysen, Carey
Operational/Managerial Control · Individual
Braden, Adam
Operational/Managerial Control · Individual
Cecil, Caitlin
Operational/Managerial Control · Individual
Cecil, Caitlin
Corporate Director · Individual
Commonspirit Health
Operational/Managerial Control · Organization
Concept Rehab, Inc.
Operational/Managerial Control · Organization
Fazio, Christopher
Operational/Managerial Control · Individual
Finn, Christina
Operational/Managerial Control · Individual
Finn, Christina
Corporate Director · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Grubbs, Stacey
Operational/Managerial Control · Individual
Grubbs, Stacey
Corporate Director · Individual
Hanson, Scott
Operational/Managerial Control · Individual
Hazard, Ted
Operational/Managerial Control · Individual
Hazard, Ted
Corporate Director · Individual
Herrera, Angela
Operational/Managerial Control · Individual
Howard, Casey
Operational/Managerial Control · Individual
Iffland, Alisa
Operational/Managerial Control · Individual
Iffland, Alisa
Corporate Officer · Individual
Keller, Michaela
Operational/Managerial Control · Individual
Lang, Trestin
Operational/Managerial Control · Individual
Lipsey, Prentice
Corporate Officer · Individual
Longhin-Howard, Joan
Operational/Managerial Control · Individual
Miller, Lori
Operational/Managerial Control · Individual
Munroe, Kyle
Operational/Managerial Control · Individual
Munroe, Kyle
Corporate Director · Individual
Murriel, Shelly
Operational/Managerial Control · Individual
Murriel, Shelly
Corporate Director · Individual
Nagel, Jennifer
Operational/Managerial Control · Individual
Nagel, Jennifer
Corporate Director · Individual
Naset-Payne, Janet
Operational/Managerial Control · Individual
Ohio Newspapers, Inc.
Operational/Managerial Control · Organization
Rebik, Mary
Operational/Managerial Control · Individual
Rehmer, Heather
Operational/Managerial Control · Individual
Rehmer, Heather
Corporate Officer · Individual
Reliant Care Pharmacy Services LLC
Operational/Managerial Control · Organization
Snodgrass, Barbara
Corporate Director · Individual
Soukup-Mcfarland, Dianne
Operational/Managerial Control · Individual
The Northern Trust Company
Operational/Managerial Control · Organization
Trosen, Ryan
Operational/Managerial Control · Individual
Ulrichpinciotti Design Group, LLC
Operational/Managerial Control · Organization
Wine, Matthew
Operational/Managerial Control · Individual
Wine, Matthew
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Childserve Habilitation Center
Johnston, IA
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Royal Oaks Nursing and Rehabilitation Center
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
#3
Brio of Johnston, LLC
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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