Stone Cottage Care Center
Inspection Findings
F-Tag F0550
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Based on observation, clinical record review, policy review, and staff interviews, the facility failed to interact with a resident in a respectful manner for 1 of 3 residents reviewed for dignity(Resident #26). The facility reported a census of 30 residents.Findings:The Quarterly Minimum Data Set(MDS) assessment tool, dated 7/17/25, listed diagnoses for Resident #26 which included heart failure, diabetes, and hemiplegia(one-sided paralysis) and listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 8/19/25, stated the resident had chronic obstructive pulmonary disease and directed staff to administer aerosol or bronchodilators(medications that treated breathing conditions) as ordered. On 9/4/25 at approximately 8:45 a.m., Staff A Certified Medication Assistant(CMA) provided the resident her Symbicort inhaler(a medication inhaled which helped with breathing conditions) and the resident inhaled 2 puffs. After this, Staff A provided the resident a glass of water and the resident swished her mouth and swallowed the water. The resident then said she had to spit and spit into a tissue. Staff A then turned to the State Agency(SA) with a disgusted look on her face as she gestured with her head toward the resident and said ew loogie. The staff member and the resident were near the dining room where other residents and staff were present. The facility policy Resident Rights, revised June 2023, stated employees shall treat residents with kindness, respect, and dignity. On 9/4/25 at 11:02 a.m., when queried regarding Staff A's comment and behavior toward the resident, the Director of Nursing(DON) stated it was not appropriate.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stone Cottage Care Center
900 South Stone Street Sigourney, IA 52591
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0658
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, clinical record review, policy review, and staff interivew, the facility failed to ensure a resident rinsed their mouth in accordance with professional standards for 1 of 1 residents reviewed for the administration of an inhaler(Resident #26). The faciltiy reported a census of 30 residents. Findings:The Quarterly Minimum Data Set(MDS) assessment tool, dated 7/17/25, listed diagnoses for Resident #26 which included heart failure, diabetes, and hemiplegia(one-sided paralysis)and listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Provision of Physician Ordered Services, dated 12/23, stated the purpose of the policy was to provide physician ordered services according to professional standards of quality. The September 2025 Medication Administration Record(MAR) listed a 3/24/22 order for Symbicort Aerosol 160-4.5 micrograms[mcg] (budesonide-formoterol fumarate, an inhaler which treats lung conditions) 2 puffs twice daily. The MAR directed staff to ensure the resident rinsed their mouth with water after the inhalation and not to swallow.The Symbicort Highlight of Prescribing Information, retrieved from https://drd9vrdh9yh09.cloudfront.net/50fd68b9-106b-4550-b5d0-12b045f8b184/a4b62ab8-1314-4583-91b4-294ec239f790/
on 9/4/25 at 1:50 p.m. stated the medication could cause infections of the mouth and throat and directed staff to advise the resident to rinse their mouth with water without swallowing after inhalation to help reduce
the risk. On 9/4/25 at approximately 8:45 a.m., Staff A Certified Medication Assistant(CMA) provided the resident her Symbicort inhaler(a medication inhaled which helped with breathing conditions) and the resident inhaled 2 puffs. After this, Staff A provided the resident a glass of water and the resident swished her mouth and swallowed the water. Staff A did not provide her a cup to spit into or encourage her to spit out the water she swished with. On 9/4/25 at 11:02 a.m., the Director of Nursing(DON) stated staff should have residents swish and spit after utilizing a Symbicort inhaler. She stated with Resident #26 they should remind her to spit out the water.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stone Cottage Care Center
900 South Stone Street Sigourney, IA 52591
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, clinical record review, policy review, and staff interview, the facility failed to notify the physician of a resident's refusal of an ordered diet and failed to carry out specialized Speech Therapy(ST) services for a diagnoses of dysphagia(difficulty swallowing) for 1 of 2 residents reviewed for a change in condition(Resident #10). The facility reported a census of 30 residents. Findings include:The Quarterly Minimum Data Set(MDS) assessment tool, dated 8/16/25, listed diagnoses for Resident #10 which included dysphagia(difficulty swallowing), Parkinson's disease(a disease which caused tremors and lack of mobility), and anxiety disorder. The MDS stated the resident had a mechanically altered diet and listed his Brief
Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The facility policy Provision of Physician Ordered Services dated 12/23, stated the facility would provide a reliable process for
the proper and consistent provision of physician ordered services according to professional standards of quality. A 7/16/25 5:40 p.m. Nursing Note stated the resident reported that he ate roast beef for lunch and it felt like it was caught in his esophagus. A 7/17/25 2:52 p.m. Nursing Note stated the resident requested a scope due to the roast beef which was stuck and stated he had this happen his whole life. The resident's provider ordered a transfer to the ER for evaluationA 7/17/25 6:26 p.m. Nursing Note stated the resident would transfer to another hospital for a scope. A 7/19/25 5:02 a.m. Nursing Note stated the resident had an endoscopy(a scope inserted through the mouth to visualize the upper digestive system) completed and was
on a liquid diet for two weeks and then would advance to a pureed diet. A 7/24/25 Care Plan entry stated
the resident had a swallowing problem.An 8/5/25 Care Plan entry stated the resident refused his pureed diet and wanted a mechanical soft diet. An 8/5/25 Fax cover Sheet from the facility to the provider stated
the resident completed 2 weeks of a full liquid diet and started a pureed diet today. The form inquired how long the resident was to have a pureed diet before advancing to a regular diet. The provider then inquired if
they had Speech Therapy (ST) and directed ST to advance the diet if able. A note on the fax stated the resident had an order for ST. On 9/3/25 at 11:25 p.m., during the noon meal service, Staff D [NAME] prepared a mechanical soft meal consisting of ground chicken alfredo for Resident #10. The Dietary Manager stated the resident refused his ordered pureed diet so they provided him with mechanical soft foods. The facility lacked documentation of the initiation of Speech Therapy (ST) services and lacked communication to the provider that the resident refused his ordered pureed diet. On 9/4/25 at 11:02 a.m.,
the Director of Nursing(DON) stated the provider wanted the facility to follow up with ST for the resident.
She stated she was not sure how often ST came into the building. On 9/4/25 at 1:36 p.m., Staff C Occupational Therapy Assistant(OTA) stated she received an order for ST at the end of July or the beginning of August and had not been able to get a therapist to visit.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stone Cottage Care Center
900 South Stone Street Sigourney, IA 52591
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
Federal health inspectors cited Stone Cottage Care Center in Sigourney, IA for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-09-04.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Stone Cottage Care Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
F-Tag F0695
Federal health inspectors cited Stone Cottage Care Center in Sigourney, IA for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-09-04.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Stone Cottage Care Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
F-Tag F0725
Federal health inspectors cited Stone Cottage Care Center in Sigourney, IA for a deficiency under regulatory tag F-F0725 during a standard health inspection conducted on 2025-09-04.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Stone Cottage Care Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
F-Tag F0759
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure
the medication error rate did not exceed 5%. The facility's medication error rate calculated as 7%. The facility reported a census of 30 residents.Findings include:The Annual Minimum Data Set(MDS) assessment tool, dated 7/10/25, listed diagnoses for Resident #8 which included anxiety, hemiplegia(paralysis affecting one side of the body), and paraplegia(paralysis affecting the lower body) and listed her Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. A Care Plan entry, revised 2/1/24, stated the resident was a smoker.The September 2025 Medication Administration Record(MAR) listed the following orders:a . 7/21/25 Famotidine(a medication used to reduce stomach acid) tablet 20 milligrams(mg) two times per day.b. 7/16/25 nicotine patch(assisted in nicotine cessation) 24 hour 14 mg/hour 1 patch one time a day. On 9/3/25 at 8:16 a.m., Staff A Certified Medication Assistant(CMA) administered Resident #8's morning medications. Staff A stated that she did not have the resident's nicotine patch. Staff A also failed to administer the resident's Famotidine. A 9/3/25 eMar Medication Administration Note stated the facility waited for the resident's nicotine patch to come in.The facility's medication administration error rate calculated as 7%On 9/4/25 at 11:02 a.m., the Director of Nursing(DON) stated staff should have called the pharmacy if a medication was not available. She stated with regard to the omission of the medication, staff should check the medications better. The undated facility policy Medication Administration, stated staff would administer medications in accordance with professional standards of practice and directed staff to follow the manufacturer's product information for inhalers.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
F-Tag F0760
Federal health inspectors cited Stone Cottage Care Center in Sigourney, IA for a deficiency under regulatory tag F-F0760 during a standard health inspection conducted on 2025-09-04.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Stone Cottage Care Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
F-Tag F0801
Federal health inspectors cited Stone Cottage Care Center in Sigourney, IA for a deficiency under regulatory tag F-F0801 during a standard health inspection conducted on 2025-09-04.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Stone Cottage Care Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
F-Tag F0865
Federal health inspectors cited Stone Cottage Care Center in Sigourney, IA for a deficiency under regulatory tag F-F0865 during a standard health inspection conducted on 2025-09-04.
Category: Administration Deficiencies
The facility was found deficient in the following area: Have a plan that describes the process for conducting QAPI and QAA activities.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Stone Cottage Care Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
F-Tag F0887
Federal health inspectors cited Stone Cottage Care Center in Sigourney, IA for a deficiency under regulatory tag F-F0887 during a standard health inspection conducted on 2025-09-04.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Stone Cottage Care Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
Stone Cottage Care Center in Sigourney, IA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Sigourney, IA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Stone Cottage Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.