Based on Electronic Health Records (EHR), document review, staff interviews, resident interview and policy review the facility failed to investigate the allegation of neglect, failed to separate Staff A, Licensed Practical Nurse (LPN) from Resident #34 and failed to take corrective actions to prevent further abuse/neglect of Resident #34. Resident #34 stated Staff A would refuse to provide or delayed providing suctioning to Resident #34 who was dependent on staff assistance for his tracheostomy (breathing tube in the neck) frequently. Resident #34 explained he would have to call the Certified Nursing Assistants (CNA's) with the call light 3 or 4 times before his tracheostomy would be suctioned by Staff A. …
F610 citations in Iowa
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F610 less often than its own record predicts
0.92 times the national share — cited less often here than elsewhere.
Of every deficiency written in Iowa in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F610 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 abuse policy review, the facility failed to separate the resident from the alleged perpetrator and failed to conduct two timely abuse investigations 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. …
Based on clinical record review, staff interviews and facility policy review the facility failed to investigate an allegation of abuse for two of three residents reviewed (Resident#29 and #9). The facility reported a census of 34 residents. Findings include:1. The Minimum Data Set (MDS) assessment for Resident#29 dated 5/6/26 listed diagnoses of schizophrenia and psychotic disorder. The MDS reflected a Brief Interview of Mental Status (BIMS) score of 7 out of 15, severe impairment. The MDS identified Resident#29 independent with walking, transfers and eating.The Care Plan for Resident #29 dated 5/28/26 directed ongoing psychiatric medication management. The Care Plan failed to identify potential behavioral risks.2. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 1.82% | 1.43× |
| 2024 | 1.26% | 0.88× |
| 2025 | 1.39% | 0.92× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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