Stone Cottage Care Center: Staffing Failures Leave Residents Waiting - IA
That was not the only time. Four days earlier, on May 21, he had to wait 30 minutes after telling a CNA he needed to be cleaned up.
When inspectors interviewed the Director of Nursing on May 22, she did not dispute any of it. She said she knows the facility is going to get cited because staff call in sick every day, especially on second and third shift. She said management has been working off-shift hours to fill gaps. She said she submitted a plan to corporate requesting a staffing level of 3.6 hours of care per resident per day, given how many psychiatric residents the facility serves. Corporate rejected it.
The CNAs described conditions that explain how a man ends up waiting more than an hour to be cleaned up.
Staff C said night shift runs with two nurses and two aides for the whole building. It used to be three aides, but one is on light duty. On weekend day shifts, two CNAs cover more than 30 residents. The facility schedules agency workers to fill gaps, but most of the time those workers call in sick or simply don't show up. One aide had worked 14 days in a row trying to keep the weekends covered. At least half the residents require two staff members for care.
Staff D, a CNA who had since left the facility, said call lights routinely go unanswered for 30 to 45 minutes, and that wait time was part of why she quit. She described working a day shift that started at 6:00 AM, staying through her scheduled end at 6:00 PM, then continuing until 2:00 AM because no one came to relieve her at 10:00 PM. She said she has worked alone with more than 35 residents while the facility tried to find someone to come in. Eleven residents require a mechanical lift for transfers. At least half require two staff members for any hands-on care.
Staff A confirmed that Resident 8, the man who waited 75 minutes, complains every day that it takes too long for anyone to answer his light.
The administrator told inspectors she would expect call lights to be answered within 15 minutes. She said she reviewed grievance logs and resident council meeting minutes and found no complaints about call lights.
The facility's own written policy, last revised in September 2022, says staff should answer the call system immediately, complete tasks within five minutes if possible, and notify a supervisor when a request cannot be fulfilled. The gap between that policy and what staff described living through every shift is not a matter of interpretation.
The Director of Nursing knew. The CNAs knew. One of them worked a 20-hour shift and still left because the conditions were not sustainable. Corporate, whoever reviews staffing plans from a distance, said no.
Meanwhile, a resident in Sigourney turned his call light on twice and waited.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stone Cottage Care Center from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 21, 2026 · Our methodology
Stone Cottage Care Center in Sigourney, IA was cited for violations during a health inspection on May 28, 2026.
Four days earlier, on May 21, he had to wait 30 minutes after telling a CNA he needed to be cleaned up.
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.