F689 in Iowa. Pick another state for the same tag.
Against expectation — 2025
Iowa cites F689 more often than its own record predicts
Versus expected share1.27×
1.27 times the share F689 takes of citations nationally.
Share of Iowa citations7.04%
Of every deficiency written in Iowa in 2025, this is the portion that was F689.
Iowa7.04%
National5.53%
Share of all citations that were F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F689 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.
J · Immediate jeopardy, isolatedAugust 10, 2026
Based on observation, record review, resident interview, staff interviews, and the facility policy, the facility failed to provide adequate supervision to prevent the elopement of Resident #25. The resident has a history of falling, behaviors of persistent exit seeking and a history of elopements at the facility without staff knowledge. On 6/23/26 at approximately 4:15 PM the resident was found outside on the front patio. The door alarms had not sounded and the staff were unaware she was outside. The staff implemented the intervention 1 on 1 as needed. On 6/24/26 at approximately 6:30 AM Resident #25 was found outside again. She was on the facility property walking toward a gravel road that led to a busy highway 50 feet away. …
Based on clinical record review, facility investigation review, personnel file review and staff interviews, the facility failed to provide adequate assistance to a resident to prevent a fall that resulted in a fracture for 1 of 3 residents reviewed (Residents #3) and failed to reeducate the staff after a resident had a suicide attempt for 1 of 1 residents reviewed (Resident #14). The facility reported a total census of 30 residents. Findings include:
1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of vitamin D deficiency, disorientation and malnutrition. …
D · No harm, potential for more than minimal, isolatedAugust 27, 2026
Based on observation, clinical record review, staff interview, and policy review, the facility failed to use foot supports while transporting a resident (#20) in a shower chair from his room to the designated shower room. The facility reported a census of 43 residents.Findings include:Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of diabetes mellitus, non-Alzheimer's dementia, and muscle weakness. It revealed he required supervision with eating, maximal assistance with toileting hygiene, bathing, and dressing, and was dependent with all other Activities of Daily Living (ADLs) and mobility. …
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