West Burlington, IA — A hospital-based nursing home in southeast Iowa is facing a proposed $10,000 state fine following the death of a long-term care resident after staff placed her in bed while she was experiencing breathing difficulties, according to state inspection records.
The citation was issued by the Iowa Department of Inspections, Appeals, and Licensing against The Klein Center, a 165-bed skilled-nursing facility operated by Southeast Iowa Regional Medical Center in West Burlington.
State inspectors reported that the resident, a woman with Down syndrome, began coughing and choking during a meal on Dec. 5, 2025. Despite signs of respiratory distress, inspectors found that staff failed to adequately assess her condition or provide appropriate follow-up care before putting her to bed.
According to the inspection report, the resident’s breathing worsened later that evening. Her oxygen levels dropped, she became unresponsive, and staff called 911. The resident died shortly afterward.
Inspectors determined that a licensed practical nurse did not conduct required vital-sign checks after the choking episode, a failure regulators said contributed to the resident’s decline.
The $10,000 penalty remains proposed and suspended while federal regulators with the Centers for Medicare and Medicaid Services review the case and consider whether to impose additional sanctions.
State records show the Klein Center was cited in 2025 for a separate violation involving verbal abuse of residents, which resulted in a $500 fine.
Facility officials have not publicly commented in detail on the citation, and the names of staff involved have not been released. No criminal charges have been announced.
Hospital-based nursing homes operate at the intersection of acute and long-term care, a structure that regulators say requires clear protocols to ensure residents receive timely assessments and interventions when medical conditions change.
