Based on clinical record review, observations, staff interviews, and facility abuse policy, the facility failed ensure the resident's right to be free from abuse on two occasions for 1 of 3 sampled (Resident #9) for abuse. The facility reported a census of 45 residents. Findings included: The Minimum Data Set assessment dated [DATE], for Resident #9, revealed a BIMS score of 6, which indicated the resident's cognition severely impaired. The MDS revealed Resident #9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident experienced behaviors not directed towards others. The Care Plan revealed Resident #9 has major depressive disorder, generalized anxiety disorder, and a mood disorder and prescribed medications to treat those disorders. …
F604 citations in Iowa
Restraints · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F604 less often than its own record predicts
0.33 times the national share — cited less often here than elsewhere.
Of every deficiency written in Iowa in 2025, this is the portion that was F604.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F604 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 observation, record review, resident, and staff interviews the facility failed to keep a resident free from physical restraints during a period of behaviors. A staff member used her body to force a resident to ambulate to her room for 1 out of 1 residents reviewed with behaviors (Resident #1). The facility reported a census of 43 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS showed Resident #1 rejected care on one to three days during the observation period, and these behaviors worsened compared to previous evaluations. Resident #1 didn't require assistance with toilet transfers, sit-to-stand transfers, and walking. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 0.12% | 0.31× |
| 2024 | 0.07% | 0.20× |
| 2025 | 0.13% | 0.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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