Bishop Drumm Retirement Center: G-Tube Medication Failure - IA
The resident, identified in inspection records only as Resident 15, has muscular dystrophy, respiratory failure, difficulty swallowing, and malnutrition. Because the resident cannot eat or swallow safely, a gastrostomy tube surgically inserted into the stomach serves as the primary route for nutrition and medication. The resident also has a tracheostomy tube to maintain an open airway, a suprapubic catheter to drain urine, and mild cognitive impairment. For eating, toileting, and transfers, the resident depends entirely on staff.
An inspector watched the nurse, identified as Staff A, sitting on the side of the resident's bed on the afternoon of September 15, 2025. Staff A was applying tape to the adaptor port at the end of the feeding tube when the inspector observed her draw up approximately 25 milliliters of pink liquid in a syringe. The liquid, Staff A explained, contained three of the resident's medications mixed with an unspecified amount of water.
Staff A attached the syringe and pushed the liquid into the tube. She did not flush the tube before administering the medications. She did not flush it after.
When the inspector asked about it, Staff A said there was no set amount for the water flush, so it didn't really matter.
The facility's own policy on medication administration through enteral tubes, revised just one day later on September 16, 2025, states that staff must flush the tube with at least 15 milliliters of water before giving any medication, and flush it again with at least 15 milliliters after. The Director of Nursing told the inspector the following morning that her expectation was for staff to follow the physician's order on flushing, and if no order existed, to follow the protocol, which calls for 30 to 60 milliliters of water before and after.
The gap between what Staff A did and what both policy and the Director of Nursing described as standard is not a matter of degree. Staff A skipped the pre-flush entirely. She skipped the post-flush entirely. She then offered an explanation to the inspector that contradicted both the written protocol and her supervisor's stated expectations.
Flushing a feeding tube before medication administration clears residue from prior feedings and helps ensure the tube is properly positioned and unobstructed. Flushing after helps move medication fully into the stomach and prevents the tube from clogging. For a resident who is already malnourished and cannot take anything by mouth, a clogged or compromised feeding tube is not a minor inconvenience.
The deficiency was cited at a level of minimal harm or potential for actual harm, and inspectors identified it as affecting few residents. The facility reported a census of 114 residents at the time of the inspection.
The inspection was complaint-based, meaning someone prompted regulators to take a closer look before the visit occurred on September 17, 2025. The records do not say who filed the complaint or what it alleged.
What the records do say is that a nurse responsible for the care of a resident who cannot breathe, eat, or move without medical assistance looked at a syringe full of medication, attached it to a tube going directly into that resident's stomach, and pushed the plunger, having skipped the step meant to protect the resident before and the step meant to protect the resident after. Then she told the inspector watching her that the amount of water involved didn't really matter.
The Director of Nursing, one floor and one day removed from that bedside, described a completely different standard.
Resident 15 was still there when the inspector left.
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 19, 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 in inspection records only as Resident 15, has muscular dystrophy, respiratory failure, difficulty swallowing, and malnutrition.
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.