Based on facility record review, hospital record review, and staff, family and Physician Assistant (PA-C) interviews, the facility failed to provide ongoing re-evaluation of [CONDITION(S)] medications (drugs capable of affecting the mind, emotions, and behavior) to ensure the least restrictive regimen possible for 1 of 3 residents reviewed with [CONDITION(S)] medication orders (Resident #4). The resident declined, became unresponsive and had been admitted to the hospital with pneumonia and acute metabolic [CONDITION(S)] secondary to medication. The facility reported a census of 56 residents. Findings include: The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had been admitted on [DATE]. …
F605 citations in Iowa
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F605 more often than its own record predicts
1.26 times the share F605 takes of citations nationally.
Of every deficiency written in Iowa in 2025, this is the portion that was F605.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F605 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 clinical record reviews, staff interview, and policy review, the facility failed to consistently monitor target behaviors (TBs) or document attempted non-pharmacologic interventions (NPIs) for 5 of 5 residents (#5, #8, #4, #30, #42) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 43 residents. Findings include:1.Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia with other behavioral disturbances, and depression. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 0.06% | 5.97× |
| 2025 | 0.89% | 1.26× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction