Based on clinical record review, staff and resident interviews, official city records, facility policy review, and guidance from the Centers for Medicare & Medicaid Services (CMS), the facility failed to provide necessary nursing coverage for approximately four hours on two nursing units housing a total of 53 residents, after one of two on duty nurses left the facility unscheduled. During this period of time, the facility failed to provide requested medications to three residents (Res #3, #6, #9). As a result, one resident's pain (Res #3) became so severe that she contacted 911 (emergency services) to obtain assistance with receiving her pain medication. …
F725 citations in Iowa
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F725 more often than its own record predicts
4.08 times the share F725 takes of citations nationally.
Of every deficiency written in Iowa in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F725 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, employee record review, staff and resident interviews, and facility policy review, the facility failed to provide adequate supervision for residents who occupied a 14 room shift assignment. This resulted in harm to Resident #3 due to her walker being left out of reach when she was put to bed, leading to a fall with injury. Staff failed to perform safety rounds and the resident was not found by staff for a significant amount of time after the fall. Additionally, other residents of the shift assignment were left without call lights in reach and others with call lights going unanswered. The facility reported a census of 50 residents. …
Based on observations, resident council notes review, staff and resident interviews, and facility policy review the facility failed to answer resident's call lights in a timely manner; within 15 minutes. The facility reported a census of 33 residents. Findings include:Observations on 8/18/2026 at 2:30 PM revealed rooms [ROOM NUMBERS] had a white light activated above their door frames. At 2:46 PM, 16 minutes had passed, room [ROOM NUMBER]'s call light was answered and shut off. At 2:47 PM, 17 minutes had passed, room [ROOM NUMBER]'s call light was answered and shut off. Observations on 8/19/2026 at 9:20 AM room [ROOM NUMBER]'s had a white light activated above the door frame. At 9:40 AM, 20 minutes had passed, room [ROOM NUMBER]'s call light was answered and shut off. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 2.77% | 3.44× |
| 2024 | 3.32% | 4.14× |
| 2025 | 3.16% | 4.08× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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