Based on observation, record review, resident, family and staff interviews and review of the facility video footage and policy and procedures, the facility failed to provide Resident #2 with the required therapeutic and modified diet, resulting in the resident choking and later died . This situation caused an immediate health and safety concern. The sample consisted of 7 residents and the facility reported a census of 67 residents. Findings include: A Certificate of Death form dated [DATE] indicated Resident #2 passed away [DATE] at 12:28 a.m. related to an injury that occurred on [DATE] at 1 p.m. when the patient aspirated a large piece of hot dog and some other food while he/she had been eating lunch. …
F804 citations in Iowa
Food palatability and temperature · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Iowa cites F804 more often than its own record predicts
1.78 times the share F804 takes of citations nationally.
Of every deficiency written in Iowa in 2025, this is the portion that was F804.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Iowa surveyors wrote
F804 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 observation, interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility failed to provide food at a palatable, attractive, and a safe and appetizing temperature to 3 of 20 residents (Residents #10, #54, #66) reviewed. The facility reported a census of 82 residents. Findings Include: 1. Resident #10's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. On 7/27/26 at 11:38 AM Resident #10 revealed the food did not taste good at the facility and it is often cold when it is served.2. …
Based on observation, direct measurement and staff and resident interviews, the facility did not ensure that foods were served at palatable temperatures. The facility reported a census of 22 residents. Findings include: 1. During observation on 8/6/18 at 11:42 AM, staff placed pureed food from a insulated container and brought it to the dining room in front of a resident who could not eat independently. At 11:56 AM a staff member sat to begin assisting the resident to eat. At that time, the food temperatures were as follows: 1. Pureed Enchilada casserole - 99 degrees Fahrenheit (F); 2. Pureed Rice side dish - 98 degrees F; 3. Pureed vegetable - 96 degrees F. On 8/6/18 at 1:40 PM, the Head Cook stated that after staff pureed food, they placed it in bowls of water in a low oven. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 1.00% | 1.02× |
| 2024 | 1.52% | 1.58× |
| 2025 | 1.64% | 1.78× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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