Stone Cottage Care Center: Staff Mocked Resident - IA
The incident occurred in front of other residents and staff in the dining room area on September 4, when Staff A administered Symbicort inhaler to Resident 26, a woman with heart failure, diabetes, and one-sided paralysis but intact mental capacity.
After the resident inhaled two puffs of her breathing medication, the assistant provided her with water. The resident swished the water in her mouth and swallowed it, then said she needed to spit and used a tissue.
Staff A then turned toward the state inspector with a disgusted expression, gestured toward the resident with her head, and said "ew loogie."
The resident's quarterly assessment from July showed she scored 15 out of 15 on cognitive testing, indicating full mental awareness of her surroundings and interactions. Her care plan from August directed staff to administer aerosol medications and bronchodilators as ordered for her chronic obstructive pulmonary disease.
Spitting after inhaler use is a common medical recommendation. Patients are typically advised to rinse their mouth and spit after using certain inhalers to prevent oral infections and other side effects.
When questioned about the incident later that morning, the facility's Director of Nursing acknowledged the behavior was inappropriate.
Stone Cottage Care Center's own policy on resident rights, revised in June 2023, explicitly states that employees must treat residents with kindness, respect, and dignity. The facility houses 30 residents.
The violation represents a breach of federal regulations requiring nursing homes to honor residents' right to dignified treatment and respectful interaction. The Centers for Medicare and Medicaid Services classified the incident as causing minimal harm with potential for actual harm.
This type of public humiliation can be particularly damaging for residents who retain full cognitive awareness of how staff treat them. Resident 26 understood exactly what was happening when the medication assistant expressed disgust at her medically necessary action.
The incident occurred during routine medication administration, a daily interaction that should maintain professional boundaries and basic human respect. Instead, the assistant chose to publicly mock a vulnerable resident's bodily function related to her medical treatment.
Federal inspectors noted the violation affected few residents, but the public nature of the mockery in the dining area meant other residents and staff witnessed the degrading treatment. This creates an environment where residents may fear similar humiliation during their own care.
The facility has not indicated what disciplinary action, if any, was taken against Staff A following the director of nursing's acknowledgment that the behavior was inappropriate.
Stone Cottage Care Center must now submit a plan of correction to continue participating in Medicare and Medicaid programs. The facility has 60 days to demonstrate how it will prevent similar dignity violations from occurring.
For Resident 26, who depends on daily breathing treatments to manage her chronic lung condition, the incident transformed a routine medical necessity into a moment of public shame. She continues to require the same inhaler medication that prompted the assistant's mocking response.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Stone Cottage Care Center in Sigourney, IA was cited for violations during a health inspection on September 4, 2025.
After the resident inhaled two puffs of her breathing medication, the assistant provided her with water.
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.