Based on observations, interviews, and record review, the facility failed to properly transfer 1 of 4 residents reviewed for mechanical lift transfers (Resident #1). Staff transferred Resident #1 into the shower without the use of a mechanical lift and a second staff person assisting directly with the transfer as directed in her Care Plan. This resulted in a fall with a fractured femur. The facility reported a census of 39 residents. Findings include: A Minimum Data Set, dated dated dated [DATE], documented that Resident #1's diagnoses included osteoarthritis, right knee pain, weakness, and unspecified hearing loss. A Brief Interview for Mental Status (BIMS) revealed a score of 10 out of 15, which indicated the resident had moderate cognitive impairment. …
F677 citations in Iowa
ADL care for dependent residents · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F677 less often than its own record predicts
0.85 times the national share — cited less often here than elsewhere.
Of every deficiency written in Iowa in 2025, this is the portion that was F677.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F677 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, resident interviews, staff interviews, and policy review, the facility failed to ensure residents were offered and provided bathing at least two times per week as specified per resident care plans for 4 of 4 residents reviewed (Residents #1, #8, #10 and #11). The facility reported a census of 41 residents. Findings include: 1.The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating intact cognition. The MDS further indicated the resident had diagnoses of Cerebral Vascular Accident (CVA)(stroke) and Hemiplegia (paralysis on one side of the body) and required assistance with showers. …
Based on clinical record review and staff interview, the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 15 residents reviewed (# 48). The facility identified a census of 49 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #48 with a brief interview for mental status (BIMS) score of 5, indicating severe cognitive impairment. The resident required limited staff assistance with toilet use, personal hygiene and extensive assistance with bathing. The resident had frequent incontinence of urine. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 3.00% | 1.08× |
| 2024 | 2.71% | 1.12× |
| 2025 | 1.94% | 0.85× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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