Hiawatha Care Center

In the surveyor’s words

From the most serious findings on record at Hiawatha Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 29, 2025

  Based on observation, staff interviews, clinical record review, employee file review and facility policy review the facility failed to transfer one out of three residents reviewed according to their Care Plan resulting in one resident obtaining a laceration to her left leg that required sutures and a blood transfusion (Resident#1). The facility reported a census of 98 residents. Finding include:The Minimum Data Set (MDS) assessment for Resident#1 dated 9/2/25, listed diagnoses of Atrial Fibrillation (irregular heart beat), heart failure, and osteoporosis The Brief Interview for Mental Status (BIMS) score 4 out of 15 (severely cognitively impaired). The MDS reflected Resident#1 dependent on staff for chair to chair transfers. […]

• No harm, potential for more than minimal, widespreadF812Jan 26, 2023

  Based on observation, staff interview, record review, review of the facility's policy and review of the Food and Drug Administration (FDA) Food Code, the facility failed to monitor the dish machine's chemical and temperature levels to ensure the dish machine was providing the correct amount of chemicals needed to sanitize dishware. These failures had the potential to increase the risk of food borne illnesses and affect 105 residents living at the facility who received food from dietary services. Findings Include: During an observation on 01/23/23 at 9:28 AM in the kitchen, the Dietary Manager (DM) tested the temperature and sanitation levels of the dishwasher (low-temp model). The dishwasher temperature read 130 degrees Fahrenheit. […]

• No harm, potential for more than minimal, widespreadF880Jan 26, 2023

  Based on observations, staff interviews, record reviews, and review of the facility's policy, the facility's failed to ensure: a. Staff performed proper hand hygiene in between glove changes during resident care for two of two residents (Resident #28 and #94); b. Staff wore the required Personal Protective Equipment (PPE) when providing care to a COVID-19 positive resident for one of one residents (Resident #255); and c. The development and implementation of an adequate water management program to prevent exposure and potential infection by Legionella for 106 facility residents, who were over the age of 65, or other residents, remained in the facility over 24 hours. Findings Include: 1. […]

• No harm, potential for more than minimal, patternF656Apr 2, 2026

  Based on clinical record review, staff interview, and facility policy review, the facility failed to develop and implement a comprehensive care plan for four of five residents reviewed for unnecessary medications (Resident #6, #9, #10, #27). Findings include: 1. The Minimum Data Set (MDS) for Resident #6 dated 2/9/26 recorded the resident reported no days of little interest in doing things or of feeling down or depressed over the 14 day lookback period. The MDS documented the resident exhibited no behavioral symptoms during the seven day lookback period. The MDS documented diagnoses that included depression. The MDS documented the resident received an antidepressant during the lookback period. […]

• No harm, potential for more than minimal, patternF804Mar 13, 2025

  Based on observation, record review, resident and staff interviews, the facility failed to maintain a safe, palatable temperature of foods served at the noon meal on 3/11/25. The facility reported a census of 101 residents. Findings include: 1. An observation of the noon meal service in the [NAME] Dining Room on 3/11/25 revealed the following: a. At 11:45 AM Staff D, cook measured the temperature of the pork loin at 201.5 degrees Fahrenheit and the turkey burgers at 155 degrees Fahrenheit. b. At 12:40 PM, the Dietary Director measured the temperature of the pork loin at 180 Fahrenheit and turkey burgers at 115 degrees Fahrenheit. c. […]