After being cited for hundreds of medication errors, an Iowa care facility for intellectually disabled adults has had its license placed on conditional status by state regulators.
The move comes five months after those same regulators agreed to waive some of the training requirements for medication aides working at New Hope Village in Carroll.
Since January 2025, New Hope Village has been repeatedly cited for failing to properly handle or administer residents’ medications and failing to properly document the medication errors by the staff.
Specific violations have included a failure to provide one resident with his prescribed medications while he was suffering from seizures, and mistakenly feeding another resident shampoo through a gastronomy tube. Most recently, state inspectors alleged that a review of facility records revealed 33 documented medication errors in the 11 days leading up to March 22, 2026.
Of those 33 errors, a “lack of adequate oversight” by the home’s governing body was blamed for 29 errors involving two of the home’s 42 clients. In 23 of the cases, no medication-error forms were filled out by the staff, inspectors alleged.
In their written report, state inspectors said the home’s director of nursing confirmed the staff failed to address recurring medication errors in the building and acknowledged that employees “have not been self-reporting, so nursing staff doesn’t know (of the errors) until an audit is completed and medication-pass times are looked at.”
As a result of those findings, the Iowa Department of Inspections, Appeals and Licensing has placed on “conditional” status the home’s license as an intermediate care facility for individuals with disabilities.
State records indicate that since Feb. 11, 2026, DIAL has been imposing a $50 per day fine for each day the facility remains out of compliance with regulations. DIAL officials said Tuesday the daily fines remain in effect, which means they would total roughly $3,500 at this point.
The administrator of New Hope Village, Lacie Tedrow, did not return calls Tuesday from the Iowa Capital Dispatch, but a staff member indicated Tedrow would be issuing a written statement at some point.
Training requirement waived by state regulators
State records show that in September 2025, in the midst of repeated medication-error violations, New Hope’s CEO at the time, Jennifer Quigley, asked DIAL for a waiver that would exempt the facility from a set of specific training requirements for certified medication aides, noting that the home had been struggling with staff turnover and had difficulty recruiting medication aides.
The training requirement calls for medication aides to successfully complete a DIAL-approved medication aide course or pass a DIAL-approved “medication aide challenge examination” administered by a community college. The home said it wanted to instead have aides trained through the Iowa Association of Community Providers.
DIAL’s interim director, Aaron Baack, agreed to issue the waiver, telling Quigley in November 2025 that the agency concluded the continued imposition of the training requirement “would pose an undue hardship” on New Hope Village.
The waiver was written to remain in effect until May 1, 2026, but in his letter to Quigley, Baack noted the waiver could be rescinded “at any time should the rights, health, safety, or welfare of residents be compromised.”
Three months later, in February 2026, inspectors from DIAL reported that the director of nursing at New Hope Village had confirmed the facility had trained only one of its 11 certified medication aides by the agreed-upon date of Jan. 31, 2026. Despite that finding, a spokesperson for DIAL said Tuesday the training waiver granted last November remains in effect.
Federal records indicate that in fiscal year 2024, New Hope Village collected more than $18.9 million in revenue, a figure that included $15.2 million from taxpayers in the form of Medicaid payments.
That year, the facility reported spending $21.2 million, leading to a $2.2 million deficit, which was comparable to the previous year’s reported deficit. The records show that as CEO of the tax-exempt nonprofit, Quigley was paid $232,421 in salary and benefits in fiscal year 2024.
State: Home reduced errors by redefining ‘errors’
State inspection reports indicate that over the past 15 months, officials at New Hope Village have repeatedly told inspectors of plans to correct the issues related to medication errors, only to later report that they had failed to do so:
January 2025 — The home was cited for failing to encourage client participation in medication administration and failing to secure client medications in a locked location, leaving “all medication cupboards unlocked” while tending to residents.
June 2025 — The home was cited for failing to administer medications according to physicians’ orders. Some clients never received their prescribed intramuscular injections, while others received their prescribed medications two to three hours late. In addition, medication-error reports were not being filled out.
July 2025 — The home was again cited for failing to administer medications according to physicians’ orders. Residents frequently received their medications more than an hour late — and, in some cases, three hours late. The home’s director of nursing allegedly stated that while providing medications more than an hour late was considered a reportable error, the staff “have not been doing medication-error reports.”
August 2025 — Inspectors reviewed eight client files and found medication errors involving all eight clients. Hundreds of medications were given one to three hours later than prescribed. In one instance, a registered nurse gave a client medication intended for another individual. A medication aide told inspectors she had shown the newly hired nurse where the medications were and questioned why, since she had received her license only two weeks earlier, she had been tasked with training a registered nurse on medication administration.
The director of nursing allegedly told inspectors there was not enough staff, and the director of clinical services said the home’s medication aides were “relatively new and inefficient in passing medications.” Inspectors reported that the director of clinical services also said staffing shortages meant medication aides and “the cook” were also working as direct support professionals in the home.
December 2025 — Inspectors reviewed records at the home and found 137 documented medications errors that occurred between Oct. 1, 2025, and Nov. 18, 2025. In some instances, residents were receiving their medications eight hours late, and errors were not being documented in the clients’ files or the nurses’ notes.
The home was cited for its governing body failing to provide adequate oversight to ensure the safe administration of medications, failing to ensure there were regular audits of medication errors, and failing to promptly address recurring medication errors. The director of nursing allegedly confirmed the home’s medication error policy had not been followed “for several months” and that medication error audits were not completed.
One of the errors involved a male client who was to have had shampoo applied to the area around his eyes, but the shampoo was instead delivered “through his gastronomy tube,” resulting in consultations with a poison-control center.
A different client experienced a seizure at the home for 25 minutes without receiving his prescribed medication, then had another seizure, lasting 20 minutes, a short time later. In both cases, the staff failed to provide the man with his prescribed seizure medication. A third client was not given his prescribed insulin when his blood sugar spiked, inspectors alleged.
February 2026 — Again, the home was cited for its governing body failing to ensure compliance with the previously agreed-upon plans to correct the medication issues. Inspectors alleged the home had attempted to address the violations related to the late administration of medications by simply “removing” from the policy manual the requirement that drugs be administered within an hour of the prescribed time so that drugs could be given two hours early or two hours late — thereby reducing the number of reportable errors.
The home’s pharmacist allegedly told inspectors she had advised against the move since it could lead to undesirable interactions between drugs when morning medications, administered two hours late, mingled with afternoon medications delivered two hours early. State officials began imposing a $50 daily fine to remain in place as long as the home remains out of compliance with regulations.
March 2026 — State officials said that while the home had implemented its plan to correct medication errors, the “actions taken by the facility’s governing body failed to correct on-going concerns related to medication administration.” State officials placed the home’s license on “conditional” status.
YOU MAKE OUR WORK POSSIBLE.
Source link
