F695 in Iowa. Pick another state for the same tag.
Against expectation — 2025
Iowa cites F695 less often than its own record predicts
Versus expected share0.78×
0.78 times the national share — cited less often here than elsewhere.
Share of Iowa citations1.73%
Of every deficiency written in Iowa in 2025, this is the portion that was F695.
Iowa1.73%
National2.20%
Share of all citations that were F695.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F695 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, isolatedJanuary 31, 2023
Based on clinical record review, family and staff interviews and facility policy review, the facility failed to assure that staff provided appropriate tracheostomy care to include the assessment of respiratory failure and failed to provide appropriate training to nursing staff on procedures during an accidental extubation (tracheostomy tube fall out), tracheostomy care and suctioning for 1 of 1 resident (Resident #12). This failure resulted in the transport by MedAir to a hospital and placed on mechanical ventilation therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The facility identified a census of 36 residents. …
Based on clinical record review, facility document review, resident interview, staff interviews, safety data sheets, and policy review, the facility failed to ensure a continuous positive airway pressure (CPAP) machine (device used to keep airway open during sleep) was filled with the correct solution for 1 of 2 residents reviewed (Resident #14) for CPAP use. Staff filled Resident #14's CPAP machine with distilled vinegar (acedic acid) instead of distilled water resulting in the resident complaining of a headache, burning eyes and altered taste. The facility reported a census of 36. Findings include: The Minimum Data Set (MDS) Assessment completed on 7/18/26 revealed Resident #14 admitted to the facility on [DATE]. …
D · No harm, potential for more than minimal, isolatedAugust 13, 2026
Based on observations, interviews and record review, the facility failed to use oxygen as ordered and failed to appropriately assess the residents who were administered oxygen (O2) for 2 out of 2 residents reviewed Resident #9 and Resident #31. The facility failed to document and assess the need for oxygen during the day, and they failed to assess oxygen saturation levels for the appropriate liter per minute flow during the day for Resident #9. The facility failed to document the liter flow rate at HS nor was there a place to document liter flow for as needed oxygen. The facility failed to accurately assess for signs and symptoms of respiratory distress, to include checking the oxygen saturation levels for Resident #31 per the physician's order. …
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