Based on clinical record review, staff interview, Physician interview, Emergency Medical Service (EMS) interview, and facility policy review, the facility failed to provide adequate care and services to maintain the highest functional status for 1 of 2 residents with gastronomy tube (GT) (Resident #2). Resident #2 had an order to have his head of bed elevated while receiving his feeding. As the nurse gave Resident #2 his feeding, they had the head of bed lowered. When Resident #2 started to vomit, the nurse stopped the feeding, but failed to elevate Resident #2's head of the bed. When the certified nurse aides attempted to assist the nurse, the nurse told them to have him lay flat. Resident #2 suffered from aspiration pneumonia and septic shock. …
F693 citations in Iowa
Tube feeding · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F693 less often than its own record predicts
0.96 times the national share — cited less often here than elsewhere.
Of every deficiency written in Iowa in 2025, this is the portion that was F693.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F693 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 electronic medical record (EMR) review, resident interview, staff interviews, and policy review the facility failed to provide care and service to an individual with a feeding tube resulting in complication of enteral feeding and medication administration for 1 of 1 residents reviewed (Resident #1). The facility failed to identify the skills and abilities needed of the direct care staff when providing enteral medications to the resident resulting in 4 hospital visits including 3 overnight stays within 4 weeks. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 4/18/25 revealed the Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive deficit. …
Based on observations, staff interviews, Electronic Health Record (EHR) review and policy review the facility failed to implement policies and procedures regarding the technical aspect of a gastrostomy feeding tube (G-Tube) by not accurately labeling and dating the enteral nutrition bag and supplies. The facility failed to provide an appropriate care plan, comprehensive assessment, appropriate infection control and physician orders for 1 of 1 residents reviewed (Resident #6). The facility reported a census of 92 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) of 0 indicating severe cognitive impairment. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 0.47% | 0.63× |
| 2024 | 0.58% | 0.82× |
| 2025 | 0.67% | 0.96× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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