State-run care facility cited for more quality-of-care violations

For the second time in less than a year, the state-run Woodward Resource Center for adults with intellectual disabilities  has been cited for placing residents in immediate jeopardy by failing to properly respond to emergencies.

As a result of the most recent findings, the center has been fined $24,500 and cited for 15 regulatory violations — an exceptionally high number. The violations are related to poor facility management, staffing, training, meal services and nursing services, and resident abuse.

The findings are tied in part to an incident that took place on Jan. 19, 2026, when a male resident of the center was found unresponsive in the bathtub. According to state inspectors, the man’s skin and the bathroom temperature were both “very hot,” with the resident’s temperature measured at 105.7 degrees.

Typically, hyperthermia sets in when a body’s core temperature rises above 104 degrees, which can lead to severe health complications and is considered a medical emergency.

About 19 minutes after the man was found in the tub, three workers carried him out of the bathroom and into his room. A short time later, they carried him out of the room and laid him on the floor of a corridor where a nearby exit door was propped open, allowing the outside cold air — at the time, it was 10 degrees outdoors — to flow over the resident.

The resident’s body temperature gradually lowered over the next 90 minutes, he vomited about three times, and eventually became somewhat responsive, according to inspectors.

The staff acknowledged that they failed to follow the facility’s emergency protocol for finding a resident in an unresponsive state, inspectors allege. That protocol calls for workers to dial extension 222 to activate the emergency-response system. That, in turn, would have triggered a call for a registered nurse or physician on duty, and for the switchboard to summon emergency assistance by calling 911.

Two workers at the facility later admitted they had not checked on the resident every 15 minutes as required, according to the inspectors’ reports. One employee asserted that he could not check on everything as he “had 500 things to do” while on duty, inspectors allege.

The resident’s physician later told inspectors the man could have experienced heat stroke or dehydration, with the potential complications including a decrease in cognitive function and the possibility of death.

Violations tied to home’s management

According to the Iowa Department of Inspections, Appeals and Licensing, Woodward failed to ensure the staff competently provided supervision as directed, and failed to consistently implement policies and procedures to ensure residents’ safety.

The inspections department also alleged the facility failed to ensure accurate information was relayed to other health care providers after a medical emergency. In addition, the home failed to consistently implement established medication administration procedures.

The findings would have resulted in a state fine of $8,000, but that penalty was tripled to $24,000 due to similar, serious violations within the previous 12 months.

An additional $500 fine was imposed because the facility’s governing body — Woodward is operated by the Iowa Department of Health and Human Services — failed to “effectively provide adequate oversight and direction to ensure clients’ health and safety.”

In addition, inspectors reviewed surveillance video that showed a residential treatment worker repeatedly shining a flashlight directly into a resident’s eyes several times while the two were alone in the facility’s “day room.”  The disabled resident responded by raising his hands over his eyes, jerking his shoulders, and shaking his head side-to-side.

When interviewed by inspectors, the worker confirmed his actions action and said he regretted them, inspectors reported. Woodward’s superintendent later confirmed the worker failed to follow the facility’s “philosophy of service,” but the inspectors’ report gives no indication as to whether the worker was disciplined.

Deaths and injuries cited in past reports

State records show the Woodward Resource Center has been cited for numerous issues over the past 15 months:

Abuse: In December 2024, Woodward was fined $325 for failing to have reported resident abuse. According to inspectors, surveillance video showed an 18-year-old resident seated and rocking in a living room recliner when a worker crossed the room, stepped behind the recliner and tried to push it forward. As the resident clutched the armrests and braced himself, the worker gave the back of the recliner a hard shove toward the floor, and the resident “somersaulted out backwards,” inspectors reported.

Death: In January 2025, the home was fined $6,500 for failing to provide adequate supervision of residents and failing to provide emergency medical responses. According to inspectors, a 22-year-old resident of the home was found dead in the facility shortly before 5 a.m. on Sept. 9, 2024. The young man had been assigned “general supervision” status, meaning the staff was to check on him every 15 to 30 minutes.

A review of video footage showed that two different workers repeatedly failed to check on the man. When the resident was found unresponsive at 4:58 a.m., three residential treatment workers were on the scene but did not initiate CPR per Woodward policy. Eventually, a nurse arrived and attempted CPR. The resident was later pronounced dead. The cause of death was later ruled to be toxic levels of clozapine – a drug that is commonly used to treat schizophrenia — although no violations related to a drug overdose were cited.

Choking: In March 2025, the home was fined $2,762 for failing to provide residents with their prescribed diets. That violation was tied to a finding that the Woodward staff provided food that not been cut into small, bite-size portions to a female resident who then choked on a serving of whole meatballs.  After the resident began to choke, a worker performed the Heimlich maneuver. After 10 abdominal thrusts, the resident’s airway was cleared.

Injuries: In June 2025, Woodward was fined $2,750 due to the staff being unable to demonstrate the skills and techniques necessary to manage residents’ behavior, and failing to provide residents with nursing services required to meet their needs. In one incident, a resident who had complained of acute abdominal pain was sent to the emergency room of a hospital, where it was discovered he had swallowed a plastic spoon while left unsupervised. In the second incident, a resident of the home was transported to the hospital a day and a half after the staff had noticed one knee was bruised, swollen and unable to bear weight.

Death: In August 2025, Woodward was cited for failing to check on, and provide CPR for, a 49-year-old male resident who subsequently died. According to inspectors, video at the home showed a state-employed residential treatment worker “sat in the living room loveseat on his cell phone,” and failed to perform 14 scheduled checks on the resident before entering the man’s room and finding him in bed, unresponsive and covered in feces.

The video of the man’s room allegedly showed workers arriving on the scene and standing about, with no one performing CPR. The man was declared dead a short time later, with the death certificate indicating he died from sepsis caused by an infection related to a perforation of the small intestine.