State: Woman died after nursing home failed to perform CPR

An Iowa nursing home where a resident died after the staff failed to perform CPR is facing a possible fine for its actions.

State inspection records indicate that a female resident of Kingsley Specialty Care was having trouble breathing the night of May 9, 2026, and asked that she be taken to a hospital. The staff reportedly tried to obtain vital signs but they “could not be read,” according to the inspectors’ report.

A registered nurse later told inspectors she went to retrieve a canister of oxygen to help the resident’s breathing, but “couldn’t find all the working parts” for the oxygen-delivery device. She then went to the basement to find the parts.

Back in the resident’s room, a nurse aide noted that the woman’s breathing had slowed down and she was no longer responsive. According to inspectors, the aide reported he  radioed the nurse “several times and she didn’t respond” then “had to yell for her.”

Once the nurse was back in the room, she reported she didn’t know whether the resident had a do-not-resuscitate order in place, inspectors allege. The nurse and an aide then went to the nurses’ station and looked for the book with each resident’s code status. They could not find it, so the nurse looked on the computer and found the woman was a “full-code” resident, indicating cardiopulmonary resuscitation, or CPR, should be performed, inspectors reported.

At that point, an aide began chest compressions while another aide called 911. The nurse checked for a pulse and said the resident “was gone” and chest compressions were halted, according to inspectors.

One of the aides reportedly told the state inspectors she had expected the nurse to take charge of the situation, but “she kind of acted like she was in shock,” the report states. The nurse reportedly told the inspectors she had been “flustered” at the time and hadn’t thought to grab the facility’s crash cart for medical emergencies and take it to the room.

The ambulance crew arrived 10 minutes after the 911 call came in and began CPR. The resident was then taken to a hospital, where she was pronounced dead.

One of the EMTs on the ambulance crew later told inspectors that when the crew arrived in the resident’s room, an employee — a nurse, she thought — was standing at the foot of the bed. The EMT reportedly told inspectors she asked the employee why no one was performing CPR on the woman, and the worker replied that she was “giving her some air.”

There was no bottled oxygen in the room, no crash cart and no Ambubag to administer respiratory support, the EMTs told inspectors.

The home’s director of nursing later showed inspectors the crash cart that was positioned near the nurses’ station. The cart contained an Ambubag and oxygen, but the director of nursing reported she did not know if the cart was used for the incident involving the woman who died.

The home was cited for failing to provide the woman with basic CPR, which would have involved establishing and maintaining an airway, providing “rescue breathing” if necessary, and external cardiac compressions

The home was alco cited for failing to report an incident of resident abuse. In that situation, a licensed practical nurse saw the facility’s charge nurse remove a resident’s medication from its packaging and then take the pill herself. The nurse who witnessed the incident reported she was “shocked” the charge nurse would take a resident’s medication directly in front of her. After the licensed practical nurse reported the incident, the charge nurse was given a verbal warning, according to inspectors.

The administrator reportedly told inspectors she did not self-report the incident to state regulators as required because the medication was not a controlled substance.

As a result of the violations, the Iowa Department of Inspections, Appeals and Licensing has proposed, but held in suspension, a $10,500 state fine. Typically, DIAL holds state fines in suspension so the federal government can decide whether to impose a federal penalty.

Kingsley Specialty Care is owned by the Iowa nursing home chain Care Initiatives. The facility has a two-star “below average” overall rating from the federal Center for Medicare and Medicaid Services.