Augustana Care Hastings Health and Rehabilitation

Inspectors wroteBased on interview and document review, the facility failed to ensure a safe transfer with a mechanical lift was performed to reduce the risk of serious harm, injury, impairment, or death for 1 of 3 residents (R1) reviewed for mechanical lifts. This resulted in immediate jeopardy for R1. The immediate jeopardy (IJ) began on 3/16/26 when nursing assistant (NA)-A and NA-B did not check to ensure all four straps of the sling were attached to the lift, resulting in a fall, fractured ribs and hospitalization for R1 and was identified on 3/19/26. The regional nursing consultant, the assistant director of nursing, the administrator, medical records, the director of nursing, and the nurse manager were notified of the IJ on 3/19/26 at 3:45 p.m. The IJ was removed on 3/17/26 and the deficient practice corrected 3/17/26 prior to the start of survey and was therefore past noncompliance.

Inspectors wroteBased on observation, interview and document review the facility failed to assess and monitor non-pressure related skin injuries for changes until resolved for 1 of 3 (R1), reviewed for quality of care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food temperatures were checked or obtained in a manner to reduce the risk for cross-contamination between food items prepared in the main production kitchen. In addition, the facility failed to ensure 1 of 1 can opener was kept in a clean and sanitary manner. These findings had the potential to affect 66 of 67 residents who consumed food from the main production kitchen.

Inspectors wroteR32 R32's annual Minimal Data Set (MDS) dated [DATE], indicated was cognitively impaired, needed maximal assistance with eating, oral hygiene, showers, upper body dressing, personal hygiene and was dependent on staff with lower body dressing, toileting hygiene and transfers. R32 also included diagnoses of dementia, non-traumatic brain dysfunction, diabetes mellitus, arthritis and anxiety disorder. R32's eating care plan printed 5/22/25, indicated R32 required extensive assistance of one staff to eat meals due to weakness and dementia. During observation on 5/19/25 at 6:00 p.m., dinner was served in the second-floor dining room. The dinner consisted of a pulled pork sandwich, tater tots, mixed greens salad and mandarin oranges gelatin. Some of the residents did not require any assistance, some needed help to set up their meals, and others required maximal assistance to eat their meals. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident's needs were addressed in a respectful and dignified manner when a resident (R12) requested incontinence assistance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident with known heart failure was routinely assessed for new or worse symptoms as directed by the discharging hospital physician for 1 of 1 resident (R15). In addition, the facility failed to comprehensively assess a non-pressure skin condition, to ensure wound change could be adequately monitored and acted upon promptly to promote healing and reduce the risk of complication (i.e., infection, worsening) for 1 of 2 residents (R51) reviewed who had skin impairments.

Inspectors wroteBased on observation and interview, the facility failed to ensure oxygen administration was administered according to physician orders for 1 of 1 resident (R11) observed for respiratory services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to appropriately monitor and comprehensively assess complaints of pain for 1 of 5 residents (R2) reviewed for pain.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a routine dental referral for a missing front tooth was followed up on along with a recommendation for an over-the-counter fluoride rinse to maintain oral health for 1 of 2 residents (R18) reviewed for dental services.

Inspectors wroteBased on observation, and interview, the facility failed to ensure appropriate infection control measures were followed related to ensuring clean personal was transported intrafacility in a method that ensured cleanliness and protected the clean laundry . This had the potential to affect all 41 residents on the long-term care floor (LTC) along with an unspecified number of residents whose laundry is done by the facility in the transitional care unit (TCU).

Inspectors wroteBased on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 4 of 5 residents (R4, R32, R34, R44) over [AGE] years old whose vaccinations histories were reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a dry-powder inhaler was administered in accordance with manufacturer instructions and current standards of care for 1 of 1 resident (R121) observed to receive inhalers during the survey.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., nail care) was completed and provided to reduce the risk of complication (i.e., infection, skin scratches) for 1 of 1 residents (R38) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure activities of interest were offered or provided to enhance quality of life for 1 of 1 resident (R19) reviewed who resided on the short-term stay (i.e., TCU) unit.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the correct application of a neck brace to minimize the risk of spinal misalignment and corresponding adverse effects for 1 of 1 residents (R34) reviewed for neck brace application.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their antibiotic stewardship program, to include proper testing, to reduce unnecessary antibiotic use to ensure good clinical outcomes and to reduce potential drug resistance for 1 of 2 residents (R4) reviewed for antibiotic stewardship who received 2 antibiotics without proper testing.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the required nurse staffing information was posted daily and updated with each shift. This had the potential to affect all 58 residents residing in the facility and/or visitors who may wish to view the information.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Office of Ombudsman for Long-Term Care (OOLTC) was notified in a timely manner of resident' hospitalizations (i.e., facility-initiated discharges) for 1 of 2 residents (R40) reviewed for hospitalization; and 11 of 11 residents identified to have been hospitalized within the last month.