Stewartville Care Center

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident assessment to self-administer medications, was implemented and followed consistently in accordance with physician orders for 1 on 1 resident (R8) reviewed for self-administration of medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure the required Notice of Medicare Non-Coverage (NOMNC) was provided timely to 1 of 3 residents (R27) reviewed for beneficiary notices.

Inspectors wroteBased on interview, observation and record review, the facility failed to develop a person-centered care plan for 2 of 3 resident (R4, R1) reviewed for hospice care and smoking. Findings Include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was moderately cognitively impaired. R4's diagnosis included dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) with moderate agitation During record review on 6/16/26 at 10:01 a.m., noted R4 was admitted to hospice on 1/30/26. R4's comprehensive care plan failed to include a resident-specific hospice care plan, including hospice diagnosis, hospice provider information, and resident choices and preferences. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide supervision to 1of 1 resident (R8) reviewed for activities of daily living who was left unattended on the toilet for more than 1 hour. Findings Include: R8's comprehensive Minimum Data Set (MDS) assessment, dated 5/11/26, identified R8 had impaired cognition and required extensive assistance with activities of daily living and maximal assistance with mobility. R8 's care plan dated 5/4/26 indicated, resident had a history of falling related to impulsiveness and perceived abilities. Motion sensor alarm to monitor movements due to unattended / unassisted transfers resulting in falls, reminders to use call light for all transfers. Record review indicated R8's had an unwitnessed fall on 6/12/26 at 10:06 a.m., in the bathroom, right beside the toilet and the wheelchair. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to complete weekly wound assessment and documentation for 1 of 1 resident (R6) reviewed for pressure Ulcer/Injury who had 2 unhealed stage 4 pressure ulcers (full-thickness skin and tissue loss, exposed bone, ligament, cartilage, or muscle) on bilateral buttocks. This had the potential to delay identification of changes in wound status and impact timely interventions to promote healing. Findings Include:R6's quarterly Minimum Data Set (MDS) assessment, dated 6/3/26, identified R6 had intact cognition and was dependent on staff for activities of daily living and mobility. MDS identified two stage 4 pressure ulcers, pressure reducing device for bed, chair and application of nonsurgical dressing and ointment. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medications were available for administration per physician order for 1 of 1 resident (R37) reviewed for pharmacy services.

Inspectors wroteBased on observations, interviews, and document review, the facility failed to protect a resident's right to be free from verbal abuse for 1 of 3 residents (R4) when R1 who had a history of cognitive impairment, personality changes, impulsiveness, and making poor choices, repeatedly yelled at R4, made a threat to shoot him in the head, and entered his room on three different occasions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to identify alternatives prior to installing or using grab bars (bars installed at the head of the bed for a resident to hold onto for bed mobility or transfers), ensure grab bars were comprehensively assessed to determine if they were appropriate and safe, discuss the risks and benefits, and obtain informed consent prior to use of grab bars for 2 of 3 residents (R3, R4) who were observed to have grab bars on their bedsR3's quarterly minimum data set (MDS) dated [DATE] indicated intact cognition with diagnoses included Type 2 diabetes and chronic heart failure. R3's care plan dated 6/16/25 indicated R3 was independent with bed mobility and utilized bilateral grab bars. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued medications were returned to the pharmacy or destroyed in a timely manner to decrease the potential for drug diversion for 1 of 1 medication rooms.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure meals were served warm/hot and palatable to promote quality of life and nutritional intake for 2 of 2 residents (R16 and R29) reviewed for dining. This had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators and dry storage were labeled, dated and discarded properly. This deficient practice had the potential to affect all 40 residents, staff and visitors who received food from facility kitchen.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure proper personal protective equipment (PPE) was utilized for 5 of 5 residents (R23, R6, R15, R21, R36) reviewed for enhanced barrier precautions (EBP).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition. This had potential to affect all 40 residents, staff and visitors who consumed meals from the main production kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R6) reviewed for nutrition and weight loss had received a supplement to increase calorie intake and weight per provider order.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise the comprehensive care plan for diabetic management that included goals and individualized interventions for 2 of 3 residents (R1, R2) reviewed for diabetic management. Findings incude: R1's face sheet identified R1 had diagnoses that included type 1 diabetes mellitus (autoimmune disease where the pancreas fails to produce insulin) with hyperglycemia (high blood sugar), unspecified diabetic retinopathy (diabetic complication that leads to vision loss) without macular degeneration, other diabetes complications unspecified, hypoglycemia (low blood sugar) without coma. R1's quarterly minimum data set (MDS) dated [DATE], identified R1 had verbal behaviors directed at others that occurred 1 to 3 days, did not reject cares, and had insulin injections daily. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to implement care planned fall interventions for 1 of 2 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who had an unwitnessed fall while self-transferring when the motion sensor alarm did not sound and failed to alert staff that R1 was self-transferring as intended per care plan. Additionally, the facility failed to determine why the motion sensor alarm did not alert staff following the fall and added a second alarm.

Inspectors wroteBased on observation, interview and document review the facility failed to report an unwitnessed fall with injury to the state agency (SA) for 1 of 2 residents (R1) reviewed for falls.

Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate an unwitnessed fall with a serious injury for 1 of 2 residents (R1) whose motion sensory alarm did not sound/alert staff of movement and R1 fell. This resulted in rib fractures and contusions to R1's face.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess, develop and implement a person centered dementia care treatment plan for 1 of 2 residents (R1) reviewed who had Lewy body dementia, was startled easily, at risk for falls, and the facility added a pressure sensor alarm to R1's bed, which sounded in her room.

Inspectors wroteBased on interview and record review, the facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutritional service. This had the potential to affect 45 of 45 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure safe food storage and kitchen cleanliness to reduce and/or prevent the risk of food borne illness. This had the potential to affect 45 of 45 residents whop obtained their meals from the kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure therapeutic diet per physician's orders were followed for 1 of 3 residents (R1) reviewed for therapeutic diets.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure controlled substances were stored and destroyed in a timely manner to prevent potential diversion. In addition, the facility failed to ensure prescribed medications were secure at all times to prevent potential diversion and/or ingestion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure community use glucometer's were properly cleaned and disinfected between patient use and complete hand hygiene for 3 of 3 residents (R10, R34, R36) observed to have their blood glucose checked with the devices. This had the potential to affect 9 of 9 residents R6, R8, R10, R15, R18, R31, R34, R36, and R39 identified in the facility with orders to obtain blood glucose monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity for 1 of 1 resident (R2) when yelling out resident's name and care information in public areas.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a resident who had been assessed to not self-administer medication, did not self-administer medication and store medications in the residents room for 1 of 1 residents (R9).

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain confidentiality of resident's personal and medical records when staff left the computer open allowing others to view the electronic medical records (EMR) and shift report notes lay open on top of the medication cart.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure licensed nurses have the competencies necessary to administer medications through g-tube (gastrostomy-tube in stomach used for administration of medications and liquid tube feeding), troubleshooting complications, and ensuring documentation of findings for 1 of 1 resident (R2) reviewed for tube feeding.

Inspectors wroteBased on interview and document review, the facility failed to act upon the consultant pharmacist ' s recommendation for 1 of 6 residents (R1) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine dental care for 1 of 1 (R2) resident reviewed for dental services.