Bishop Drumm Retirement Center: Pressure Injury Harm - IA
The deficiency, cited at the "actual harm" level, means inspectors determined that real injury occurred, not merely a risk of it.
Pressure injuries, sometimes called bedsores, develop when sustained pressure cuts off blood flow to skin and underlying tissue. For residents who are immobile or spend long hours in bed, they are among the most preventable, and most serious, harms a nursing facility can cause. Left unaddressed, they can progress from surface redness to deep wounds that reach bone, become infected, and prove fatal.
Bishop Drumm's own written policies described exactly what the facility was supposed to do. A policy on turning and repositioning directed staff to document repositioning schedules in each resident's care plan, calibrated to the individual's tissue tolerance, mobility, skin condition, medical condition, and personal preferences. The same policy required that heels be floated off the surface of the bed using pillows or specialized devices. The requirement was explicit: even when a heel protector is in use, the heel must still be floated.
A separate facility policy on pressure injury prevention and management, revised just six days before the inspection on September 11, 2025, committed the facility to preventing avoidable pressure injuries and to treating any that developed, preventing infection, and stopping new injuries from forming. It described a systematic approach: prompt assessment, identification and removal of underlying risk factors, monitoring whether interventions were working, and adjusting the plan when they were not.
Licensed nurses, the policy stated, were required to conduct full-body skin assessments on every resident at admission, weekly thereafter, and again after any new pressure injury was identified. Those findings were to be documented in the medical record. The interdisciplinary team was then responsible for developing a care plan with measurable goals.
The gap between those written commitments and what inspectors actually found was the basis for the citation.
The inspection was triggered by a complaint, meaning someone, whether a resident, a family member, or another individual, contacted regulators with concerns before inspectors arrived. Complaint inspections are targeted; inspectors come in looking at something specific. The fact that they found actual harm, rather than a lesser violation, indicates the concern that prompted the complaint had substance.
Bishop Drumm Retirement Center is a continuing care retirement community on Winwood Drive in Johnston, a suburb of Des Moines. It operates under CMS provider number 165448.
The facility's plan of correction was not included in the inspection document. CMS directs anyone seeking that information to contact the facility or the Iowa state survey agency directly.
What the record shows is a facility that had updated its pressure injury prevention policy less than a week before inspectors walked through the door, and still received an actual harm citation on the same subject. Whether that policy revision was prompted by the complaint, by internal quality review, or by something else, the inspection report does not say.
What it does say is that residents were harmed.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 28, 2026 · Our methodology
Bishop Drumm Retirement Center in Johnston, IA was cited for violations during a health inspection on September 17, 2025.
The deficiency, cited at the "actual harm" level, means inspectors determined that real injury occurred, not merely a risk of it.
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.