Based on clinical record review, staff interviews, and policy review the facility failed to follow the physician's order to complete blood sugar (BS) checks and administer intravenous (IV) antibiotics for a resident with diabetes and an infection and failed to notify the physician when an IV antibiotic was not available/or able to be administered for 1 (Resident #1) of 3 residents reviewed. The resident was re-hospitalized for sepsis and had high blood sugars. The facility reported a census of 42 residents. Findings include:The Minimum Data Set (MDS) for Resident #1, dated 9/9/25, included diagnoses of diabetes, septicemia (presence of bacteria in the blood stream), renal (kidney) failure, and aphasia (impairment in a person's ability to comprehend or formulate language). …
F658 citations in Iowa
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F658 more often than its own record predicts
2.29 times the share F658 takes of citations nationally.
Of every deficiency written in Iowa in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F658 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, observation, staff interview, and policy review, the facility failed to follow the physician's order and flush a gastrostomy tube (g-tube) with the ordered amount of water for one of two residents observed for g-tube medication administration (Resident #61). The facility also failed to administer nasal spray as directed for one of one residents observed during medication administration (Resident #28). Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had diagnosis of malnutrition. The MDS indicated the resident had a feeding tube. The Care Plan initiated 4/17/26 revealed the resident required a tube feeding related to dysphagia (difficulty swallowing). The resident was dependent for tube feeding and water flushes. …
Based on clinical record review and staff interview, the facility failed to follow physician orders [REDACTED]. (Resident #8 ) The facility census was 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #8 had [DIAGNOSES REDACTED]. The assessment indicated the resident required extensive assistance of staff with bed mobility. Discharge Instructions dated 8/10/17, from the hospital included the resident continued on the same turning schedule and required a Dolphin bed (rotating water bed) for 6 weeks. A Rental Invoice form dated 8/31/17, indicated the facility rented a Dermafloat mattress system (rotating air mattress) rather than a Dolphin bed. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 5.00% | 3.13× |
| 2024 | 5.81% | 3.54× |
| 2025 | 4.09% | 2.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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