Citations in Iowa
Statistics, citations and compliance trends for long-term care facilities in Iowa.
Statistics for Iowa (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Iowa
Staff used personal cell phones to take and share resident-related images and video without consent. A CNA admitted taking a Snapchat photo of a severely cognitively impaired resident’s soiled brief and thighs, and another CNA admitted sending a Snapchat video of a male resident urinating in a trash can to other CNAs. Interviews showed staff knew photos and videos of residents were not allowed, even when faces were not visible.
Failure to Report Staff Video of Resident Urinating: A CNA showed another CNA a video of a male resident urinating in a trash can in the chapel, and the video was also shared in a Snapchat group with other CNAs. The staff member who saw it did not report it because she believed the resident was fully dressed and did not think it was inappropriate, despite having abuse-reporting training. The DON later learned of the incident through another RN and interviewed the CNA, who admitted sending the video and gave changing accounts of what was shown.
A resident with dementia and independent transfer status was physically forced by a CNA during an attempted transfer to supper after she said no. Witnesses reported the CNA grabbed both arms, pulled on the resident’s forearms, and tried to lift her into a wheelchair without a gait belt, while the resident resisted and later reported pain. The resident was found with two new bruises on the forearm, and multiple staff described the CNA as rough, rushed, and inappropriate with residents.
Food Preparation Not Performed Using Sanitary Practices: A Cook was observed preparing pureed meals while repeatedly touching bread, utensils, the robo coupe blade, and other nonfood surfaces with gloved hands before continuing food prep. The Cook also handled bread and pureed food with the same gloves, and both an LPN and the Regional Dietician stated these actions were not appropriate for sanitary food handling; the facility policy required proper hygiene and sanitary practices to prevent food borne illness.
The facility failed to notify the LTC Ombudsman of hospital transfers and discharges for 3 residents. EHR and progress note review showed that two residents were admitted to the hospital and one resident was sent to the ER for surgical opinion and later discharged, but the Notice of Transfer Form did not include these events. Staff and the Administrator acknowledged the omissions, and the facility lacked a policy for the notifications.
The facility failed to ensure MDS assessments accurately reflected resident condition for two residents. One resident’s MDS did not show the Level II PASRR outcome despite documentation that the resident needed NF services and specialized behavioral health/developmental services. Another resident had a PEG tube, tube feeding orders, and observed enteral feeding, but the MDS did not document the feeding tube even though the RN signed that the assessment was accurate.
Abuse Prevention Failure Involving Resident Images and Video
Penalty
Summary
The facility failed to ensure two residents were free from abuse when staff used personal cell phones to take and share images and video involving residents without consent. One resident had severe cognitive impairment with a BIMS score of 0, was dependent on staff for toileting hygiene and toilet transfers, was always incontinent of bowel and bladder, and required a mechanical lift and two staff for transfers. Staff K, a CNA, admitted she took a Snapchat image of that resident’s soiled brief with stool present, showing the resident’s lower thighs and the brief unfolded between her legs, and sent it to a friend who was not a facility staff member. She acknowledged the action was inappropriate. A second resident also had severe cognitive impairment with a BIMS score of 5 and diagnoses including encephalopathy, cancer, BPH, renal failure, UTI, dementia, depression, and neutropenia. Staff I, a CNA, admitted she sent a video through Snapchat of a male resident urinating into a trash can in the chapel to a group of five other CNAs. Staff I described the video as showing the resident in the background while she was taking a selfie, and later stated the video included a caption identifying the resident. Other staff interviewed denied receiving or seeing the video, while one staff member reported being shown the video in a locker room setting. Staff I gave changing descriptions of what was visible in the video, but repeatedly acknowledged she had taken and shared it. Facility interviews and investigative statements documented that staff understood they were not allowed to take photos or videos of residents with personal phones, even if the resident’s face was not visible. The facility policy stated residents must not be subjected to abuse, including taking or distributing photographs or recordings that demean or humiliate a resident, and prohibited using smart phones or other devices to take, keep, or distribute such images or recordings through social media or multimedia messages. The events involved staff taking resident-related images and video on personal devices and sharing them outside appropriate channels.
Failure to Report Staff Video of Resident Urinating
Penalty
Summary
The facility failed to report an incident involving a male resident after staff took a video of him and shared it in a Snapchat group chat. The resident had a significant change MDS with a BIMS score of 5, indicating severe cognitive impairment, and diagnoses including encephalopathy, cancer, benign prostatic hyperplasia, renal failure, UTI, dementia, depression, and neutropenia. The record also showed he required supervision or touching assistance for toileting hygiene and was occasionally incontinent of urine and frequently incontinent of bowel. According to the investigative file, a CNA stated she was shown a video by another CNA in a school locker room and laughed at it, but did not report it because she did not think anything inappropriate had occurred since the resident was fully dressed. The CNA later acknowledged she had taken mandatory reporting training and had been educated on abuse reporting. The DON was notified after another RN reported hearing about the video, and the DON then interviewed the CNA involved. During the investigation, the CNA admitted she had sent the video in a Snapchat group consisting of five other CNAs at the facility. She described the video as showing the male resident urinating in a trash can in the chapel, with her face also appearing in the frame. On a later interview, her account changed and she stated the video may have shown herself with a caption about the resident urinating, and she denied being certain the resident was visible. The facility policy stated that allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation should be reported immediately to the charge nurse, who is responsible for immediately reporting to the Administrator or designated representative.
Physical Abuse During Resident Transfer
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member when a CNA physically forced the resident to transfer after the resident said she did not want to go to supper. Resident #14 had severely impaired cognitive skills for daily decision making, short- and long-term memory problems, and diagnoses including heart failure, hypertension, non-Alzheimer’s dementia, arthritis, and osteoporosis. The resident’s care plan described her as independent with transfers and ambulation, including use of a cane in her room and a front wheeled walker in the hallway. According to the investigation, a staff member reported witnessing CNA Staff E grab the resident by both arms and yank her out of a chair. Another staff member described the interaction as excessive and over the top, stating the resident said no when asked to go to supper and that Staff E pulled on the resident’s forearms without a gait belt. The same witness reported that Staff E physically tried to pick up the resident and force her into a wheelchair, while the resident twisted, turned, and attempted to get away. Staff E stated she performed a pivot transfer after the resident agreed to transfer, and denied reaching for the resident’s arms. The resident reported pain after the incident and later stated that pulling on her arms hurt. A head-to-toe assessment documented two new bruises on the left forearm, and wound documentation identified two in-house acquired bruises on the left outer forearm. Additional staff interviews described Staff E as rough with residents, quick, rushing them, and not understanding or having patience with dementia residents. Several staff members stated they had previously raised concerns about her tone, roughness, and interactions with residents, and one staff member wrote that many staff and residents had complained that she was rude and rough with residents.
Food Preparation Not Performed Using Sanitary Practices
Penalty
Summary
The facility failed to prepare food in accordance with professional food safety standards. During observation of food preparation, Staff C washed her hands, used towels to remove pans of rice and pork stir fry from the convection oven, and placed the towels on the preparation table. She then scooped rice and pork stir fry for 7 pureed meals, wiped her hand on one of the towels, and proceeded to open a bread bag and don gloves while handling bread, utensils, and equipment during the preparation process. Staff C used gloved hands to place bread on a cutting board, operate the robo coupe, add liquid from the pork stir fry, remove additional bread from the bag, straighten stacked bread slices, and cut the bread while holding it with her gloved hand. She also touched the robo coupe blade and scraped the sides of the bowl with a rubber spatula, including using one hand to scrape food off the spatula. Staff C later stated she did not recall touching the bread or pureed mixture with gloved hands that had touched multiple nonfood surfaces, and Staff E and the Regional Dietician both reported that Staff C should not have touched the bread, pushed the robo coupe blade down, or scraped off the spatula with gloved hands that had contacted nonfood surfaces. The employee file showed Staff C was a Cook whose job description required sanitary food handling, and the facility policy directed staff to use proper hygiene and sanitary practices to prevent food borne illness.
Failure to Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of discharges for 3 of 6 residents reviewed: Resident #13, Resident #122, and Resident #126. Review of the electronic health record showed Resident #13 had hospital paid leave effective 3/28/26, and a progress note dated 3/29/26 documented that the resident had been admitted to the hospital. However, the Notice of Transfer Form to the LTC Ombudsman did not include this hospitalization. For Resident #122, the EHR showed hospital unpaid leave effective 3/26/26, and a progress note dated 3/26/26 documented admission to the hospital, but the Notice of Transfer Form lacked this hospitalization. For Resident #126, the EHR showed hospital paid leave effective 2/24/26 and stop billing effective 2/28/26. A progress note dated 2/24/26 documented the resident was sent to the emergency room for surgical opinion, and a progress note dated 2/27/26 documented the resident was being discharged. The Notice of Transfer Form to the LTC Ombudsman did not include the 2/24/26 hospitalization or the 2/28/26 discharge. During interview, Staff A, Interim Social Services, stated Residents #13 and #126 had not been included on the Notice of Transfer Form, and the Administrator acknowledged the facility lacked a policy and that both residents should have been included in the notifications.
MDS Assessments Did Not Accurately Reflect PASRR Status and Feeding Tube
Penalty
Summary
The facility failed to complete MDS assessments that accurately reflected resident condition for two residents. For one resident, the MDS dated 8/23/25 indicated the resident was not considered by the state Level II PASRR process to have serious mental illness, intellectual disability, or a related condition, even though the chart contained a Notice of PASRR Level II Outcome dated 3/27/25 stating the resident needed the level of services provided in a nursing facility and specialized services for behavioral health and/or developmental condition. The MDS Coordinator reviewed the record and confirmed the MDS failed to show the Level II PASRR outcome and did not accurately reflect the resident’s status. For another resident, the care plan identified tube feeding and directed staff to check placement and gastric contents/residual volume per facility protocol, and the resident’s hospital discharge summary documented a left PEG tube. Physician orders included enteral feeding, water flushes, and residual checks, and staff observed the resident receiving PEG tube feeding. However, the MDS assessment did not document a feeding tube in Section K, despite the RN who completed the section signing that the assessment accurately reflected resident information. The MDS Coordinator acknowledged the resident had a feeding tube since original admission and stated the MDS assessment was inaccurately coded.
Find your facility
Search by name to see its inspection history, citations and penalties — and how to prepare for the next survey.
Get alerted when Immediate Jeopardy citations hit in Iowa — free
You're all set
Compliance trends in Iowa
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Iowa
- Staff education was provided to ensure all staff and departments are aware that oxygen equipment cannot be on residents or in the designated smoking area while residents smoke. (J - F0689 - IA)
- Facility educated Resident #32 and other residents who smoke that oxygen equipment cannot be with them while smoking. (J - F0689 - IA)
- Facility posted signs near the exit to the designated smoking area and the front entrance for visitors, stating that oxygen use is not allowed while smoking. (J - F0689 - IA)
- Facility planned audits for compliance to ensure oxygen equipment is not present in the designated smoking area while residents are smoking, with any concerns to be reported to the Administrator immediately and addressed in the facility Quality Assurance meeting. (J - F0689 - IA)
Safety Lapses in Smoking Area and Resident Transport
Penalty
Summary
The facility failed to ensure the safety of residents in a designated smoking area, particularly concerning Resident #32, who was observed smoking with a portable oxygen tank attached to his wheelchair. Despite the facility's policy prohibiting oxygen use in smoking areas, Resident #32, who had been on oxygen since November 2024, was seen smoking with the oxygen tank present, posing a significant safety risk. The resident, diagnosed with paraplegia, COPD, and asthma, was non-compliant with continuous oxygen orders and required supervision while smoking. However, the supervision provided by housekeeping staff was inadequate, as they did not remove the oxygen tank before the resident smoked. Additionally, the facility failed to ensure the safe transport of Resident #25, who was moved from the dining room to his room in a wheelchair without foot pedals. Resident #25, diagnosed with dementia and severe cognitive impairment, required extensive assistance for mobility. The lack of foot pedals during transport posed a risk to the resident's safety, as confirmed by the Director of Nursing, who stated that the expectation was for staff to use wheelchair pedals when transporting residents. These deficiencies highlight the facility's failure to adhere to safety protocols and provide adequate supervision, resulting in Immediate Jeopardy to the health and safety of the residents. The facility's policies and procedures were not effectively implemented, leading to unsafe conditions for residents who required special care and supervision.
Removal Plan
- Staff education provided to ensure all staff and all departments are aware oxygen equipment cannot be on residents or in the designated smoking area while residents smoked. All staff educated prior to the start of their next shift.
- Facility educated Resident #32, and the other residents who smoke, that oxygen equipment cannot be with them while smoking.
- Facility posted a sign near the exit to the designated smoking area stating that oxygen use is not allowed in the designated area.
- Facility posted a sign near the front entrance for visitors stating that oxygen use is not allowed while smoking.
- Facility planned to audit for compliance to ensure oxygen equipment not present in the designated smoking area while residents are smoking and any concerns to be reported to the Administrator immediately and addressed in facility Quality Assurance meeting.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.
