Based on clinical record reviews, staff interview, and policy review, the facility failed to develop a personalized Care Plan that included resident specific target behaviors (TBs) or non-pharmacological 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 also failed to develop a personalized Care Plan that included the use of insulin and diuretics. 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. …
F656 citations in Iowa
Comprehensive care plan · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F656 less often than its own record predicts
0.93 times the national share — cited less often here than elsewhere.
Of every deficiency written in Iowa in 2025, this is the portion that was F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F656 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 observation, review of clinical records, and interviews, the facility failed to develop and implemented a comprehensive person-centered care plan for 1 of 15 sampled (Resident #33). The facility reported a census of 49. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #33 had [DIAGNOSES REDACTED]. Resident #33 had bowel and bladder incontinence. The Care Plan failed to reflect Resident #33 had incontinence. During an observation on 3/4/20 at 9:50 a.m. revealed Resident #33 incontinent of bowel and bladder and the staff provided incontinence care. During an interview on 3/5/20 at 10:21 a.m., the MDS Coordinator stated she overlooked placing interventions on the Care Plan for Resident #33's incontinence.
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 3.24% | 0.90× |
| 2024 | 2.99% | 0.88× |
| 2025 | 3.20% | 0.93× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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