Stewartville Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Feb 2, 2023

  Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure ulcer interventions for 1 of 3 residents (R1) who was admitted to the facility without pressure ulcers. The facility failed to provide ongoing comprehensive skin assessments, monitor for signs of infection/deterioration and ensure R1 was seen at the wound clinic per physician orders. As a result, R1 had a life threatening infection that required an above the knee amputation resulting in an immediate jeopardy. The IJ began on 12/20/22, when R1 was transferred to hospital-B for left above knee amputation related to diagnoses of osteomyelitis (bone infection) and calcaneus sepsis (life threatening bone infection that has spread through the body) from R1's pressure ulcer. […]

• Immediate jeopardy, isolatedF600Jan 30, 2023

  Based on interview and document review, the facility failed to ensure residents were free from neglect when they allowed two nursing assistants (NA)-A, NA-B, who were suspected of chemical impairment to work in the facility. NA-A and NA-B both tested positive for illicit drugs. 3 of 3 residents (R2, R3, R4) sustained falls that resulted in injuries when NA-A and NA-B did not follow the care plan. This resulted in an immediate jeopardy (IJ) for resident health and safety when NA-A and NA-B provided care. The IJ began on 1/18/23, when the facility failed to ensure residents were free from neglect when they allowed two nursing assistants who tested positive of chemical impairment to work in the facility. […]

• Actual harm, isolatedF600Apr 7, 2026

  Based 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.Findings include: R4's admission minimum data set (MDS) dated [DATE], he was cognitively intact, no depression or behaviors. He was occasionally incontinent with bowel movements and frequently incontinent with urination. His care areas triggered activities of daily living, urinary incontinence, falls, and pressure ulcers. […]

• Actual harm, isolatedF689Jun 12, 2024

  Based 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. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, anxiety, and depression with severe cognitive deficits. R1 used a wheelchair and walker, was frequently incontinent of bladder and occasional incontinent of bowel. […]

• No harm, potential for more than minimal, widespreadF801May 24, 2024

  Based 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. Findings include: During an interview on 5/24/24 at 9:12 a.m., [NAME] (C)-A, indicated the previous DM walked out earlier this month and the regional manager quit in April (2024). C-A had been doing the orders and the schedule for the past week. During a clarifying interview on 5/24/24 at 12:30 p.m., C-A stated she has not had any formal training for DM position and there was [NAME] currently in training for that position. […]