Based on clinical record review, interviews with staff and residents and policy review the facility failed to meet a resident's needs related to adequately planned transfers for 1 of 3 residents reviewed (Resident #1). The facility discharged Resident #1 abruptly after allegations of abuse to a homeless shelter that did not know of her transfer. The homeless shelter did not have nurses on staff to meet her medical needs and they did not have any staff overnight. The homeless shelter transferred Resident #1 to the hospital as she could not safely remain in the homeless shelter. After arriving to the homeless shelter, Resident #1 began to stumble and fall. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/23/23 on 11/9/23 at 4:00 PM. …
F622 citations in Iowa
Transfer and discharge · Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Iowa cites F622 less often than its own record predicts
0.68 times the national share — cited less often here than elsewhere.
Of every deficiency written in Iowa in 2024, this is the portion that was F622.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F622 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 review, staff and family interview, the facility failed to ensure that the transfer or discharge met all documentation requirements necessary for a safe and effective transition of care for one of four residents reviewed. (Resident #1) The facility reported census was 25. Findings include: According to a Quarterly Minimum Data Set (MDS) with a reference date of 7/12/24, Resident #1 had short- and long-term memory deficits and severely impaired cognitive status for daily decision making. Resident #1 required maximal to dependent assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1 was always incontinent of bladder and was frequently incontinent of bowel. …
Based on clinical record review, staff interview, and facility policy review, facility staff failed to provide transfer documentation to the facility that Resident #9 and Resident #112 transferred to for care. The sample included three residents for transfer documentation, and concerns with two of them. The facility reported a census of 61 residents. Findings include: 1. The Health Status Note (HSN) for Resident #9 dated 10/26/21 at 2:00 p.m. documented staff received a call from the digestive disease clinic for a follow up appointment on 11/4/21 to complete a paracentesis (drainage of fluid from the body with a device). The HSN documented that the resident's belly measured 47 (unknown if inches or centimeters), and the resident is unable to wait for the follow up appointment. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 0.47% | 1.86× |
| 2024 | 0.22% | 0.68× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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