Based on observations, record review, resident, and staff interviews, the facility failed to report an allegation of abuse to the Administrator, as well as the State Survey Agency within the mandated timeframe (2 hours). This resulted in a failure to protect a resident from further harm. Resident #51 reported he told staff about a staff member who grabbed his arms, hurt him, and resulted in multiple dark purple bruises to forearms. The facility's failure to report an allegation of abuse prevented an investigation into the incident, as a result, the harm continued to occur. This failure resulted in Immediate Jeopardy to the health, safety and security of the resident.The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/5/25 at 4:15 PM. …
F609 citations in Iowa
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F609 less often than its own record predicts
0.98 times the national share — cited less often here than elsewhere.
Of every deficiency written in Iowa in 2025, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F609 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 review of clinical records, staff interviews, and facility abuse policy, the facility failed to notify the State Agency within 24 hours of an allegation of abuse for 1 of 3 residents 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 Resident #9 ' 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. …
Based on clinical record review, staff interview, and facility policy review, the facility failed to ensure staff reported an allegation of staff to resident abuse timely to the facility Administrator and to the Iowa Department of Inspections, Appeals, and Licensing for 1 of 7 residents reviewed (Resident #4). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 5/7/26 revealed Resident #4 had diagnoses that included non-Alzheimer's dementia, diabetes, anxiety, depression, and post traumatic stress disorder. Per the assessment, Resident #4 scored 4 out of 15 points on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 2.41% | 1.22× |
| 2024 | 1.66% | 0.73× |
| 2025 | 2.40% | 0.98× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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