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
Failure to Maintain Separation Between Residents With Known Aggression: A resident with a known hx of resident-to-resident physical aggression struck another resident in the head with a cane in the dining room, causing a bump, laceration, and bruising. The assaulted resident was non-ambulatory, dependent on staff for transfers, and had dementia, while the aggressive resident had intact cognition, used a cane, and had a care plan for prior physical altercations. Staff placed the residents in the same area with limited supervision, and the aggressive resident stated the other resident deserved it and that he would hit him again.
Missing controlled medications and incomplete narcotic counts: Two residents had opioid medications missing from the narcotic drawer, including a hydromorphone bubble pack and a hydrocodone bubble pack, with related count sheets also missing. Staff interviews and narcotic logs showed shift-to-shift counts were not consistently completed or signed by both nurses, and staff reported that narcotic counts were often not done when carts changed possession. One resident had severe cognitive impairment and chronic pain, and the other had moderate cognitive impairment with acute pain related to fractures and dislocation.
Delayed response to activated call lights was identified for a resident with intact cognition who required assistance with toileting, transfers, and ambulation and had care plan interventions for impaired mobility, safety, weakness from TIA, and fall risk. The resident reported staff often shut off the call light without providing help, and alarm records showed multiple response times over 15 minutes, including several lasting more than 30 minutes and up to nearly an hour. Staff and the DON acknowledged that response times had exceeded the expected timeframe, and the facility policy required staff to respond to engaged call lights in a timely manner.
Failure to update lift recliner safety with cognitive decline: A resident with worsening BIMS scores and intermittent confusion, sundowning, and hallucinations was not given a formal safety assessment for her lift recliner despite changing transfer needs and staff/family reports of fluctuating cognition. Staff later found her on the floor in front of the recliner with the chair elevated; she sustained forehead and nose lacerations and a CT showed an acute C1 fracture.
A resident with severe cognitive impairment and a physician-ordered puree diabetic diet was given a peanut butter and jelly uncrustable during a snack pass after asking for more food. Staff later stated they did not know the item was not appropriate for a puree diet and that diet lists were not available to them at the time. The resident choked, became unresponsive, lost her pulse, and required CPR and EMS intervention; hospital records noted a small pneumothorax and rib fractures related to CPR.
An unlocked medication cart was found at the nurses' station with no staff present while residents were nearby in the dining/living area. The cart contained stock meds, prescribed meds for multiple residents, and other medications and supplies. An LPN later identified herself as the nurse assigned to the cart and stated she should have locked it before walking away. Facility leadership stated carts must be locked when not in use, and the policy required carts to be securely locked when out of the nurse's view.
Failure to Maintain Separation Between Residents With Known History of Aggression
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one resident struck another resident in the head with a cane in the main dining room. The assaulted resident was non-ambulatory, dependent on staff for bed-to-chair transfers, used a Broda wheelchair, and had diagnoses including non-Alzheimer’s dementia and depression. He had a BIMS score of 12 out of 15 and was documented as having potential verbally aggressive behaviors toward other residents related to dementia. After the assault, he was found with a 5 cm bump and a 1 cm laceration to the left forehead, along with facial bruising, and he stated he felt unsafe around the other resident. The resident who struck him had a BIMS score of 13 out of 15, walked with a cane, transferred independently, and had diagnoses including stroke and depression. His care plan identified a history of resident-to-resident physical aggression and directed staff to monitor for agitation, assist him to a quiet area, and maintain separation from the other resident. Despite that history, he independently approached the other resident in the dining room and struck him multiple times with the cane. During the interview, he stated the other resident deserved it and said he would hit him again if he saw him, indicating the assault was intentional and unprovoked. The investigation also documented a prior resident-to-resident altercation between the same two residents in which the aggressive resident had struck the other resident in the face with his cane several times, causing bruising to the eye and cheek. Staff statements showed the two residents were placed in the same dining area with limited supervision, and staff were occupied with other residents when the assault occurred. Several staff members stated they believed the aggressive resident was simply walking back to his room and did not realize he would attack the other resident. The facility’s investigation concluded that previously identified supervision and separation interventions were not consistently maintained, allowing the aggressive resident to reach and assault the other resident again.
Missing controlled medications and incomplete narcotic counts
Penalty
Summary
The facility failed to protect residents from misappropriation of property when controlled medications became missing from the medication carts for two residents. A self-report to the Department of Inspections, Appeals and Licensing documented that 54 doses of hydromorphone for one resident and 13 doses of hydrocodone for another resident were missing from the narcotic drawer. The report also stated that the torn top of one resident’s hydromorphone bubble pack was later found in the shred box, and that the resident’s narcotic count sheet was missing from the binder. The facility also reported that the other resident’s hydrocodone bubble pack and narcotic count sheet were missing, and the pharmacy record showed the resident should have had 13 doses remaining. One resident had a BIMS score of 2 out of 15 and diagnoses including heart failure, hypertension, non-Alzheimer’s disease, anxiety, and depression. That resident’s care plan addressed chronic pain and directed staff to anticipate pain needs and respond immediately to complaints of pain. The physician order was for hydromorphone 2 mg tablets, 0.5 tablet by mouth every 2 hours as needed for shortness of breath or pain, and the June MAR showed multiple doses were administered. The second resident had a BIMS score of 11 out of 15 and diagnoses including non-Alzheimer’s disease, anxiety, and depression. That resident’s care plan addressed acute pain related to fractures and dislocation, and the June MAR ordered hydrocodone-acetaminophen 5/325 mg, 1 tablet by mouth every 6 hours as needed for pain. The narcotic count sign-off logs showed multiple shifts with missing signatures or only one signature, including entries for both medication carts and the Midwest hall. Staff interviews showed that narcotic counts were not consistently completed when carts changed possession. Staff K stated she did not count narcotics with the RN when she came on duty and later found the hydromorphone bubble pack missing when attempting to administer the medication. Other staff stated they did not do narcotic counts, that counts were rarely done, and that they did not always count together at shift change. The DON stated the expectation was to count narcotics any time the cart changed possession, with both staff signing at the same time. The facility policy required the oncoming and outgoing licensed nurses to physically count and reconcile narcotics at each shift change and to document the count and signatures.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to consistently respond to activated call lights within a timely manner for one resident. Resident #47 had a BIMS score of 15 out of 15 and required partial/moderate assistance with toileting hygiene and toilet transfers. The resident’s care plan identified impaired mobility, safety concerns, functional performance deficits related to weakness from a transient ischemic attack, and risk for falls, with interventions directing staff to keep the call light within reach, encourage use of it for assistance, and provide prompt response to requests for help. During observation, Resident #47 stated the call light had been activated for several minutes and was shut off by staff without assistance being provided, and the resident reported this happened often. Staff F acknowledged shutting off the call light when unable to assist the resident to the bathroom. Review of the facility’s excess response alarms showed multiple call light response times for Resident #47 ranging from 16.7 minutes to 57.3 minutes. Staff interviews confirmed that an appropriate response time was under 15 minutes, and the DON acknowledged that call lights had exceeded 15 minutes at times. The facility policy stated all staff were to respond to an engaged call light to rule out an emergency situation and that resident needs such as transfers, toileting, and dressing were to be addressed in a timely manner.
Failure to Update Lift Recliner Safety With Cognitive Decline
Penalty
Summary
The facility failed to adapt safety interventions in response to a resident’s worsening cognitive impairment and changing transfer needs. The resident’s MDS assessments showed a declining BIMS score over time, from 12 to 11 and then 10, and the care plan identified impaired cognitive function with directions to monitor, document, and report changes. The resident also had an ADL performance deficit care plan that changed over time from stand aid assistance to EZ stand assistance, then to Hoyer lift assistance, and later included lift recliner supervision/assist. Prior to the addition of the lift recliner notation, the care plan did not address the resident’s use of the lift recliner. Clinical notes and staff interviews documented increasing confusion, sundowning, hallucinations/delusions, and episodes of delirium in the months before the fall. Staff and family described the resident as intermittently confused, sometimes mixing up remotes, and at times raising the recliner herself. The Medical Director documented cognitive and behavioral changes, worsening sundowning, and a positive mini cognitive screen. The resident’s daughter and multiple staff members reported fluctuating confusion, but the facility did not complete a formal safety assessment for the resident’s lift recliner use before the incident. On the day of the fall, a CNA found the resident on the floor in front of her recliner after the call light was activated. The resident was lying face down on her right side with her head against the nightstand, and the lift chair was noted to be in an elevated position. The resident sustained deep lacerations to her forehead and nose, was transported to the hospital, and a CT scan showed an acute C1 fracture. Facility staff stated the resident had been able to operate her chair remote independently and that no safety assessment had been done because there had been no reason to do one.
Improper Texture Food Served to Resident on Puree Diet
Penalty
Summary
The facility failed to provide a resident with food prepared in a form designed to meet her individual needs and according to her physician-ordered puree diet. The resident had severe cognitive impairment, was dependent on staff for eating, and had diagnoses including schizophrenia, diabetes mellitus, and stroke. Her care plan and electronic health record documented a puree diabetic diet with regular liquids and supervision/cueing with meals, along with monitoring for chewing difficulty, pocketing, and slow eating. During an evening snack pass, staff gave the resident ice cream and then, after she said she was still hungry, provided a peanut butter and jelly uncrustable sandwich. Staff later stated the resident requested the sandwich and that they did not know it was not appropriate for a puree diet. Staff also stated there were no diet lists posted for staff to look at until after the incident, and one staff member said she was not sure what foods would be considered pureed. The resident was sitting upright in the commons area when she began choking, and staff observed wheezing, stridor, and the universal sign for choking. Staff attempted the Heimlich maneuver and back thrusts without success. The resident became pale, lost consciousness, and had no palpable pulse. CPR was started, oxygen was applied, and 911 was called. EMS later suctioned peanut butter from the resident's posterior pharynx. Hospital records documented that she had a choking episode while eating at the facility, required resuscitation, and was found to have a small pneumothorax and rib fractures related to CPR. The facility's investigation confirmed that the resident had been given a peanut butter and jelly sandwich despite being ordered a puree diet.
Unlocked Medication Cart Left Unsecured at Nurses' Station
Penalty
Summary
The facility failed to properly secure and store medications to minimize loss or access for 1 of 3 medication carts. During continuous observation, an unlocked treatment cart was found at the nurses' station with no staff present while 6 residents were seated in the nearby living/dining area. The cart contained stock medications in the top right drawer, prescribed medications for 12 residents in the second right drawer, prescribed medications for 9 residents in the third right drawer, and liquid laxative, inhalers, nebulizer solution, antacids, and cough syrup in the bottom right drawer. The top left drawer contained scissors and a pill cutter, the second left drawer was locked, and the third left drawer contained lancets. At 3:43 PM, the Administrator approached the open medication cart and asked where the nurse was. An LPN then came to the nurses' station, confirmed the cart was unlocked by opening a drawer, stated it was not her medication cart, and locked and secured it. Later, another LPN identified herself as the nurse assigned to that cart since 6:00 AM and stated she should have locked the medication cart before walking away. The Interim DON stated staff know medication carts must be locked when not in use and that education had been provided, and the Regional Director of Clinical Services stated medication carts are expected to be locked when not in use. The facility's policy stated medication carts must be securely locked at all times when out of the nurse's view and locked and parked at the nurses' station when not being used.
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 Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 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): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 August 26, 2026) and official state health department websites — never guesswork.
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.
