Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Bishop Drumm Retirement Center
Johnston, IA · 150 certified beds · Last Life Safety survey July 21, 2025
CMS Certification Number 165448 · first certified June 2002
Ownership
Operated by COMMONSPIRIT HEALTH · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IA
17 citations — more than 74% of the 387 certified nursing homes in IA. Compared within IA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (June 2026 to August 2026), and past the point by which nine in ten IA facilities have been surveyed. This facility’s last Life Safety survey was July 2025. Facilities in IA are typically surveyed 11–13 months after the last one (median 12), measured over 700 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
18 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in IA, and nationally. Surveyors differ markedly between states, so the IA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 17 |
| Median facility in IA | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 29, 2023 | 7 |
| September 19, 2024 | 2 |
| July 21, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2024-09-19 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-07-21 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2025-07-21 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 1 | 2025-07-21 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2023-06-29 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2023-06-29 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2025-07-21 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-07-21 |
What the citations cover
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 3
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 21, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 28, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 28, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 28, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 28, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (July 28, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 28, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (July 25, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 25, 2025) |
September 19, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (October 11, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 25, 2024) |
June 29, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 11, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 29, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Waiver has been granted (August 31, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 11, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 11, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (July 11, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 14, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.