F628 in Iowa. Pick another state for the same tag.
Against expectation — 2025
Iowa cites F628 more often than its own record predicts
Versus expected share1.40×
1.40 times the share F628 takes of citations nationally.
Share of Iowa citations1.31%
Of every deficiency written in Iowa in 2025, this is the portion that was F628.
Iowa1.31%
National0.93%
Share of all citations that were F628.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F628 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.
D · No harm, potential for more than minimal, isolatedAugust 27, 2026
Based on clinical record review, policy, and staff interview, the facility failed to notify the Long term Care (LTC) Ombudsman for 3 of 4 residents who transferred to the hospital (Resident #1, #43, and #66). The facility reported a census of 72 residents. Findings include:
1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The MDS included diagnoses of chronic respiratory failure and acute pulmonary edema.
Resident #1's Hospital Summary date 3/12/26 documented he was admitted to the hospital on [DATE] and discharged back to the nursing facility on 3/12/26. …
B · No harm, potential for minimal, patternMay 19, 2026
Based on record review, staff interviews, and the facility policy, the facility failed to thorough document transfers to the hospital (Resident #2 and Resident #13); failed to provide the resident and/or the resident's representative a transfer notice, in writing, for 2 of 2 residents reviewed for hospitalization (Resident #1, Resident #11). The transfer notice also failed to include the resident appeal rights, the Ombudsman contact information, and the contact information for those agencies responsible for the protection of residents with intellectual, developmental, mental and related disabilities. This failure impacted all residents transferred to the hospital. …
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