Stone Cottage Care: Swallowing Safety Failures - IA
The 30-bed facility never told the resident's physician that he was refusing his prescribed pureed diet. Staff gave him mechanical soft foods instead, directly contradicting medical orders put in place after an emergency room visit and endoscopy procedure.
Resident 10 scored 14 out of 15 on cognitive testing, indicating he understood his situation clearly. His diagnoses included dysphagia, Parkinson's disease, and anxiety disorder. The facility's own assessment listed him as requiring a mechanically altered diet due to his swallowing difficulties.
The trouble started July 16 at 5:40 p.m. The resident told nurses he had eaten roast beef for lunch and it felt caught in his esophagus. The next afternoon, he requested a scope procedure because the roast beef was still stuck. He told staff this had happened to him his whole life.
His doctor ordered an immediate transfer to the emergency room for evaluation. By 6:26 p.m. on July 17, nursing notes showed the resident would transfer to another hospital for the scope procedure.
The endoscopy revealed the severity of his swallowing problems. Hospital discharge instructions on July 19 placed him on a liquid diet for two weeks, then advancement to pureed foods. The facility added a swallowing problem to his care plan on July 24.
But the resident had other ideas about his diet. On August 5, care plan entries showed he refused the prescribed pureed foods and wanted mechanical soft diet instead. The same day, the facility faxed his physician asking how long he should remain on pureed foods before advancing to a regular diet.
The doctor's response was clear: arrange speech therapy evaluation and let the therapist determine if the diet could be safely advanced. A note on the fax confirmed the resident had an order for speech therapy services.
Nobody followed through.
On September 3, during the noon meal service, dietary staff prepared ground chicken alfredo for Resident 10. The Dietary Manager told inspectors the resident refused his ordered pureed diet, so they provided mechanical soft foods instead. The facility had no documentation showing they had initiated speech therapy services or informed the physician about the resident's diet refusal.
The Director of Nursing admitted the next day that she wasn't sure how often speech therapists came to the building. She knew the provider wanted them to follow up with speech therapy for the resident, but seemed unclear about the arrangements.
An Occupational Therapy Assistant revealed she had received the speech therapy order at the end of July or beginning of August but had been unable to get a therapist to visit the facility. More than a month had passed since the doctor's orders.
The facility's own policy, dated December 23, promised "a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality." Inspectors found the opposite: a resident with documented swallowing problems eating food his doctor had specifically prohibited, with no speech therapy evaluation to determine if it was safe.
Federal inspectors determined the facility failed to provide appropriate treatment according to physician orders for the resident's dysphagia. The violation carried a finding of minimal harm or potential for actual harm.
The resident's medical journey from choking on roast beef to receiving ground chicken alfredo instead of prescribed pureed foods illustrates a breakdown in communication between dietary staff, nursing, and physicians. His intact cognitive abilities meant he understood exactly what was happening to his care, making his situation more frustrating as staff ignored medical orders designed to prevent another choking episode.
Stone Cottage Care Center reported a census of 30 residents at the time of inspection. The facility has not indicated when speech therapy services will begin for Resident 10 or how they will ensure physician diet orders are followed in the future.
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 30-bed facility never told the resident's physician that he was refusing his prescribed pureed diet.
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.