Nursing home cited for violations after resident dies by suicide

A Montgomery County nursing home has been cited by the state for violations related to a resident’s death by suicide.

According to state inspectors, the staff at the Red Oak Rehabilitation and Care Center knew for several months that a female resident of the home was suicidal and that as far back as February 2026 — six months before her death — she had been found with an article of clothing wrapped around her neck and had been placed on suicide watch.

On Feb. 23, 2026, the staff reported the woman was saying she wanted to die and that she had grabbed a trash bag and indicated she was going to kill herself with it, inspectors alleged.

In the weeks that followed, the woman continued to demonstrate a pattern of behaviors that included stating she was going to hell and that it was too late to ask for forgiveness, the inspectors reported.  “I’m in a shell now,” the woman allegedly told workers at the home. “I am not really alive anymore.”

On Aug. 10, 2026, a nurse was called into the resident’s room at 9:43 p.m. by a certified nursing assistant who had found the woman with a plastic trash bag over her head. The woman had a faint pulse but was declared dead two minutes later, according to inspectors.

Facility records indicated the woman had previously attempted suicide by choking herself with a call-light cord, inspectors alleged.

The facility was cited for failing to notify the woman’s primary care provider of her “continued comments of wanting to die,” failing to initiate CPR, and failing to immediately call 911 after she was found.

While the woman had been found at 9:43 p.m., the emergency dispatch center was not notified until 10:05 p.m., and emergency medical personnel were not asked to respond until 10:18 p.m., according to inspectors.

A $10,000 state fine was proposed by the Iowa Department of Inspections, Appeals and Licensing but that fine has been held in suspension until federal officials determine whether a federal penalty is warranted.