Based on Electronic Health Records (EHR), document review, staff interviews, resident interview and policy review the facility failed to prevent neglect when Staff A refused to provide or delayed providing suctioning for Resident #34 who was dependent on staff assistance for his tracheostomy (breathing tube in the neck). Resident #34 stated Staff A, Licensed Practical Nurse (LPN) refused to suction him nearly nightly when he worked at the facility. The resident experienced psychosocial harm as evident by severe anxiety, fear of being unable to breath and dying. Staff A worked at the facility 9/17/25 - 11/12/25 on the overnight shift with the last day of training with a second nurse on 10/4/25. Schedule documented Staff A was the only nurse when working the overnight shift when scheduled. …
F600 citations in Iowa
Abuse and neglect · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F600 less often than its own record predicts
0.66 times the national share — cited less often here than elsewhere.
Of every deficiency written in Iowa in 2025, this is the portion that was F600.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F600 findings written in Iowa, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observations, interviews, and record reviews, the facility failed to ensure residents were protected from physical abuse and mental anguish, and failed to provide adequate supervision and effective behavioral interventions to prevent resident-to-resident altercations and intrusions for 4 of 4 residents reviewed for behaviors and safety (Resident #1, Resident #2, Resident #3, and Resident #4). The facility reported a census of 34 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. Resident #1 demonstrated an ability to understand and be understood by others with no vision problems. …
Based on observation, clinical record review, facility investigation, and staff and resident interviews, the facility failed to ensure residents remained free from resident to resident sexual abuse for two of three residents reviewed (Resident #2 and Resident #3). Resident #2 showed her breasts to Resident #3, and Resident #3 exposed his penis in front of Resident #2. On 8/16/26, the facility staff self-reported the incident to the Department of Inspections, Appeals, and Licensing. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 1.06% | 0.60× |
| 2024 | 1.19% | 0.51× |
| 2025 | 1.73% | 0.66× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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