Hospital-based nursing home cited for resident death

A southeast Iowa hospital where a long-term care resident died after being put to bed while struggling to breathe is now facing a potential $10,000 fine.

The Iowa Department of Inspections, Appeals and Licensing has proposed a $10,000 fine against the 165-bed skilled-nursing facility at West Burlington’s Southeast Iowa Regional Medical Center, known as The Klein Center. That fine is being held in suspension while the federal Centers for Medicare and Medicaid Services determines whether a federal penalty will be imposed in place of the proposed state fine.

According to state inspectors, the staff at the Klein Center failed to perform a proper assessment and failed to intervene when a female resident with Down syndrome coughed, choked and vomited during the evening meal on Dec. 5, 2025.

Inspectors reported that a certified nurse aide alleged that as she and a licensed practical nurse sat talking near the dining area, a male resident of the facility approached them, reported that a female resident was choking and coughing, and asked the nurse to check on her. According to the CNA, the nurse said, “OK,” but didn’t follow up.

About 10 minutes later, the CNA allegedly told inspectors, another resident of the facility approached the nurse and said a woman in the dining area was choking, had turned red in the face and had vomited.

At that point, the nurse checked on the woman, determined she was choking, and encouraged her to spit out any sputum before assisting her from the dining area to her room. Once in her room, the woman “continued to cough with copious amounts of sputum coming up,” inspectors reported, and was unable to take drinks of water or swallow.

‘Maybe this will help’

The CNA reportedly told inspectors that although the woman appeared to be struggling to breathe, the nurse left the room, then returned with the woman’s evening medications. The nurse “placed the pills in (the woman’s) mouth and gave her some water, but (the woman) continued to cough and gag, eventually spitting out” the pills, the CNA reportedly told inspectors.

The state inspectors reported that the nurse then instructed the woman to lie down in bed, with her head elevated, and placed the woman’s CPAP, or Continuous Positive Air Pressure, mask in place, saying, “Maybe this will help.”

According to inspectors, the CNA later told them she “questioned in her head whether it was a good idea putting the woman in bed when she was still coughing but dismissed it since the LPN was the charge nurse.”

Later in the evening, a certified nurse aide noted the woman was pale, had labored breathing, and had thrown up in her CPAP mask. Two nurses were called to the resident’s bedside where they noted the woman’s oxygen levels — which are considered dangerous when they fall below 92 percent — had dropped to 34 percent and the woman was no longer responsive.

The staff called 911, but pronounced the woman dead a short time later.

Inspectors reported that when they asked the licensed practical nurse whether she had performed any patient assessments after the choking episode — such as checking the woman’s lung sounds, vital signs and oxygen levels — the nurse “teared up and stated, ‘No.’”

Resident abuse cited in May 2025

In May 2025, Southeast Iowa Regional Medical Center’s Klein Center was fined $500 by the state for resident abuse. In that case, a CNA had reportedly confronted a male resident of the home who had expressed concerns about the welfare of a fellow resident.

The CNA allegedly told the male resident not to worry about the other residents and “sit your f—ing ass down.” A worker also reported hearing the CNA call the male resident a “b—” while asserting that she knew “how to do my f—ing job.” The employee told inspectors the CNA had called a different resident a “b—” many times and was generally very vulgar to the residents.

A second employee reportedly told inspectors the CNA once gave a shower to a female resident who complained the water was too hot, prompting the CNA to tell her “shut the f— up.” The employee who reported the matter said the resident was crying afterward and asking why the CNA was mean to her.

In all, three staff members told inspectors they were aware of the CNA’s verbal abuse of residents but didn’t report it, in part because they had to work with her regularly.

Federal records indicate that during the past three years, Southeast Iowa Regional Medical Center’s Klein Center has been fined once by the Centers for Medicare and Medicaid Services. The facility has a three-star, or average, overall rating from CMS.

This article was first published by Iowa Capital Dispatch.