Bishop Drumm Retirement Center: Family Not Notified - IA
The resident, identified only as Resident #10 to protect confidentiality, depended entirely on staff for eating. Their diagnoses included anemia, diabetes, traumatic brain injury, malnutrition, and respiratory failure. More than half of their daily calories came through a feeding tube. They could not speak for themselves in any meaningful way. The facility's own assessment classified their cognition as severely impaired.
On June 5, a dietary note recorded that the resident had lost 8.8 pounds in a single week, a 5 percent drop. The facility's dietician recommended switching the tube feeding formula to stop the slide. There is no documentation in the clinical record that anyone called the family.
The weight kept falling.
By August 11, the dietician's note recorded an 11.9-pound loss in one month and a 21.4-pound loss over three months, a 12.4 percent drop. Three days later, on August 14, the dietician recommended increasing the tube feeding rate to prevent further loss. Again, the clinical record contained no documentation that the family had been told.
Inspectors reviewed the record and found nothing. On September 16, they asked the Director of Nursing directly. She confirmed she could not locate any family notification for the weight loss in the medical record. She said she would expect such notifications to be documented. Then she offered an explanation: she said she had multiple conversations with the family herself and simply did not write them down.
That answer did not satisfy the inspection standard. Undocumented conversations are, in the world of clinical records, the same as conversations that never happened. The family of a resident with severe cognitive impairment, losing weight at a rate that triggered clinical intervention twice in three months, is entitled to know what is happening. Whether the Director of Nursing spoke with them informally and chose not to document it, or whether those conversations did not occur as described, inspectors had no way to verify either way.
The facility's own notification policy, revised as recently as March 2025, stated its purpose was to ensure the facility promptly informs residents and notifies their representatives when there is a change requiring notification, including significant changes in physical condition or circumstances requiring altered treatment. A 21-pound weight loss in a resident already diagnosed with malnutrition, requiring two separate dietician interventions, fits that description without ambiguity.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and cited it as affecting a small number of residents. Bishop Drumm reported a census of 114 residents at the time of the inspection.
The inspection was complaint-driven, meaning someone prompted regulators to look at the facility before the standard survey cycle brought them there.
What the record cannot answer is what the family knew, and when. A resident who cannot advocate for themselves, whose body was losing weight faster than clinical staff could reverse it across an entire summer, had a family somewhere. Whether they were receiving calls that simply went unwritten, or whether they spent June, July, and August unaware that their family member had lost the equivalent of a small child's body weight, is a question the clinical record leaves open.
The Director of Nursing's explanation, that she had the conversations but did not document them, may be true. It may also be the kind of answer that sounds reasonable in the moment and becomes harder to believe the longer you sit with it. Inspectors found no evidence either way. Neither will the family, if they ever try to piece together what happened that summer from the records they are entitled to request.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bishop Drumm Retirement Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 18, 2026 · Our methodology
Bishop Drumm Retirement Center in Johnston, IA was cited for violations during a health inspection on September 17, 2025.
The resident, identified only as Resident #10 to protect confidentiality, depended entirely on staff for eating.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.