Stone Cottage Care Center: 7% Medication Error Rate - IA
The same morning, the assistant also failed to administer the resident's stomach acid medication. No documentation explained why.
Those missed doses contributed to a facility-wide medication error rate of 7 percent — exceeding the federal limit of 5 percent that nursing homes cannot cross without facing violations. The facility reported a census of 30 residents during the September inspection.
Resident 8, who has anxiety and paralysis affecting both one side and the lower portion of her body, maintained intact cognition with a score of 14 out of 15 on her mental status assessment. Her care plan from February 2024 identified her as a smoker, and her medication orders included a 14-milligram nicotine patch applied once daily to help with cessation.
On September 3 at 8:16 a.m., Staff A administered the resident's morning medications but skipped both the nicotine patch and her famotidine, a 20-milligram tablet prescribed twice daily to reduce stomach acid.
The medication assistant told inspectors she didn't have the resident's nicotine patch available.
A facility note from that same day stated the staff "waited for the resident's nicotine patch to come in." But no similar explanation appeared for the missing stomach medication.
The Director of Nursing acknowledged the failures during an interview the following day. Staff should have called the pharmacy when a medication wasn't available, she told inspectors. Regarding the omitted famotidine, "staff should check the medications better."
The facility's own policy on medication administration directs staff to follow professional standards of practice and manufacturer guidelines. But the policy didn't prevent the systematic errors that pushed the facility's mistake rate to nearly double the federal threshold.
Federal regulations cap nursing home medication error rates at 5 percent to protect residents from the consequences of missed or incorrect doses. Facilities that exceed this limit face citations for failing to maintain basic pharmaceutical safety standards.
The violation affected few residents, according to the inspection report, but highlighted broader medication management problems. When staff don't have required medications on hand or fail to administer prescribed doses without proper documentation, residents miss treatments their doctors deemed medically necessary.
For Resident 8, the missed nicotine patch could have triggered withdrawal symptoms or undermined her smoking cessation efforts. The skipped stomach acid medication left her without protection against ulcers and gastric irritation that famotidine is designed to prevent.
The inspection found no evidence that staff attempted alternative solutions when the nicotine patch wasn't available. They didn't contact the pharmacy for an emergency supply, didn't notify the resident's physician about the interruption in treatment, and didn't document any clinical reasoning for the omission.
The famotidine failure appeared even more straightforward — staff simply missed giving a medication that should have been readily available as part of routine morning administration.
Stone Cottage Care Center's 7 percent error rate means that out of every 100 medication administrations, seven involved mistakes. While the facility characterized the harm level as minimal, the pattern suggests systemic problems with medication management that could affect any resident at any time.
The Director of Nursing's response indicated awareness of proper procedures — calling pharmacies for missing medications and double-checking before administration. But that knowledge didn't translate into practice when Staff A faced missing medications during her morning rounds.
Federal inspectors documented the violations during a complaint investigation, suggesting someone reported concerns about medication practices at the facility. The inspection occurred on September 4, just one day after the documented medication errors.
The violation represents a fundamental failure in one of nursing homes' most critical daily functions. Residents depend on staff to deliver prescribed medications accurately and on schedule, particularly for conditions requiring consistent treatment like nicotine addiction and gastric protection.
When error rates climb to 7 percent, residents face increased risks of symptom recurrence, treatment interruptions, and potential complications from missed doses. The federal 5 percent threshold recognizes that some errors are inevitable in healthcare settings, but draws a line at levels that compromise resident safety and care quality.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stone Cottage Care Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Stone Cottage Care Center in Sigourney, IA was cited for violations during a health inspection on September 4, 2025.
The same morning, the assistant also failed to administer the resident's stomach acid medication.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.