Four Iowa nursing homes cited for alleged resident injuries or abuse

Four Iowa nursing homes have been cited recently for alleged resident injuries or abuse, with one of the cases resulting in a resident’s death, state records show.

According to state inspection reports, a resident of the Laurens Care Center was in the dining room on Oct. 6, 2026, and was heard making “sneezing noises” several times. A nurse checked on the woman and saw that her eyes were closed, she had lost consciousness and was unable to respond when shaken.

The staff took the woman to her room, where employees noted that while she still had a pulse, her oxygen levels were critically low and she was gasping for breath. The staff then transferred the woman to her bed, according to inspectors.

Inspectors allege the home’s medical records indicate that at 8 a.m., 15 minutes after the woman was seen appearing unconscious in the dining room, an employee began cardiopulmonary resuscitation and a police officer arrived on the scene.

However, inspectors reviewed the video collected by the police officer’s body camera and reported that the video shows the officer arriving in the room just before 8:02 a.m., with the director of nursing standing in the doorway, with two nurses and an aide inside the room. “Observation of the footage revealed CPR was not being done,” inspectors reported.

One nurse could be seen asking the director of nursing, “Do you want us to start it?” with the director of nursing stating, “Nothing we could have done by the time we transferred her,” and telling the officer she was “pretty sure” the resident was dead.

Staff ‘standing around … and not doing CPR’

The video footage showed the three workers inside the room “standing around the bed talking and not doing CPR,” the inspectors reported.

According to the inspectors, within a few minutes the director of nursing reported to the police officer that the resident’s daughter wanted CPR performed. By 8:05 a.m., the officer had applied a defibrillator to the resident’s chest, and the device had signaled that chest compressions should be performed, which the police officer initiated.

For the next 10 minutes, the inspectors reported, the officer and the staff performed chest compressions, but without providing any ventilations or “rescue breaths,” which are typically considered part of the CPR process.

A nurse later told inspectors she had performed about 20 chest compressions on the resident before the police officer arrived and before a backboard could be placed between the resident and the bed’s mattress.

The nurse reportedly said that once the backboard was in place “no one in the room did anything,” adding that she was not sure what the facility’s policy was with regard to CPR.

The medical examiner’s subsequent report listed the resident’s cause of death as cardiac arrest stemming from a foreign body obstructing her airway, according to inspectors.

In proposing a $10,000 state fine, the inspectors stated “basic CPR refers to a means of opening and maintaining an airway, and providing ventilation through rescue breathing” in addition to chest compressions.

The proposed state fine is being held in suspension while the Center for Medicare and Medicaid Services determines whether a federal penalty is warranted.

The Iowa Capital Dispatch was not able to reach the home’s administrator, JaimeDodd, for comment.

Other Iowa nursing homes recently cited for violations include:

Luther Manor at Hillcrest in Dubuque: State inspectors proposed a $5,750 state fine for medication errors, then tripled that to $17,250 due to the repeat nature of the offense, and then held the entire fine in suspension due to the potential for federal penalties. Inspectors alleged the home’s certified medication aide gave a resident six different medications that had been prescribed for a different resident who shared the same first name. The aide had reportedly failed to check the two residents’ last names prior to dispensing the drugs.

The error resulted in an overdose that lowered the receiving resident’s blood pressure and slowed their heart rate, leading to a 12-hour emergency department evaluation, treatment with intravenous fluids, and the administration of emergency medications.

Luther Manor at Hillcrest has been repeatedly cited for violations over the past 16 months:

— July 2025: A $5,000 fine was held in suspension after the home was cited for a safety violation tied to a degraded, sparking electrical cord in a resident’s room.

— September 2025: A $7,750 fine was held in suspension after the home ran out of a resident’s painkillers, causing the resident to be sent to a hospital emergency room to receive pain medication.

— November 2025: A $4,250 fine was held in suspension after the home failed to remove a medication patch from a resident’s body before applying a new patch, resulting in the resident being admitted to a hospital for treatment of acutely altered mental state.

— February 2026: An $8,250 fine was held in suspension after the home failed to take measures to prevent three residents from falling and sustaining injuries.

The home’s administrator, Cassandra Johnson, declined to comment on the facility’s regulatory issues when contacted Thursday by the Iowa Capital Dispatch.

Azria Health Prairie Ridge in Mediapolis: State inspectors proposed, then held in suspension, a fine of $8,250 for a medication error that resulted in a resident of the home receiving an “acute toxic overdose” of an opioid. The resident had allegedly been given two doses of morphine, each of which was 10 times the prescribed dosage. After the resident became unresponsive and deemed to be “actively dying,” the staff had to administer two doses of Narcan to revive her, inspectors reported.

According to the inspectors’ report on the matter, the certified medication aide who had delivered the overdoses later explained that she “did not confirm the dose because she did not know how to do that and only looked at the type of medication.”

The Iowa Capital Dispatch was not able to reach the home’s administrator, Cara Pagan, for comment.

Bedford Specialty Care in Taylor County: State inspectors proposed, then held in suspension, a $6,000 fine for failing to protect two residents of the home from abuse. One of the residents complained that three sisters who worked in the home as certified nursing assistants were routinely mean to her, made derogatory comments about her incontinence and ignored her requests for assistance. A license practical nurse backed up that claim, inspectors said.

A second resident of the home voiced similar concerns with the three CNAs, saying the sisters were disrespectful, physically rough with her, mocked her, belittled her, and told her she was a baby who needed to wear diapers – allegations that were backed up by another employee of the home.

One of the sisters, a resident complained, would answer a call-light by entering the room, shutting off the light, and then leaving, telling her the resident she did not have time to provide assistance. The resident told inspectors the three sisters were “pushy, bullies, and have been horrible” since they first began working at the home.

The home’s assistant director of nursing reportedly told inspectors she didn’t like the three sisters and that on one occasion, a resident who was incontinent had asked for assistance and the three sisters responded by telling the woman no one liked her because she urinated in her pants.

The Iowa Capital Dispatch was not able to reach the home’s administrator, Amanda Cozad, for comment.