Based on clinical record reviews, observations, resident and staff interviews, and facility policy review the facility failed to ensure 2 of 3 residents (Resident #1 and #8) care plans were updated timely after they both left the facility unannounced and unattended. The facility reported a census of 33 residents. Findings include:1. According to an admission Minimum Data Set (MDS) assessment tool with a reference date of [DATE] documented Resident #1 was admitted to the facility on [DATE]. The MDS documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score suggested no cognitive impairment. A Progress Note dated [DATE] at 10:36 AM documented on [DATE] Resident #1 left the facility to go to a nearby lake, unattended and without staff's knowledge. …
F657 citations in Iowa
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F657 more often than its own record predicts
1.44 times the share F657 takes of citations nationally.
Of every deficiency written in Iowa in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F657 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 and staff interview the facility failed to revise and implement interventions on the comprehensive Care Plan to include hospice services for 1 of 1 residents (Resident #27) reviewed. The facility reported a census of 34 residents. Findings include: Resident #27 Minimum Data set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The MDS documented diagnoses of progressive neurological conditions, coronary artery disease, and depression. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 4.30% | 2.00× |
| 2024 | 3.28% | 1.72× |
| 2025 | 2.70% | 1.44× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction