Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dewitt Nursing Home during CMS and state inspections, most recent first.
Expired OTC medications were found stored with active medications in the medication storage room, including cough and congestion elixir, calcium, and acid reducer bottles with past expiration dates. An LPN confirmed the items were removed and taken to the DON for disposal, and the DON acknowledged she missed some expired OTC items while stocking and checking expiration dates. Facility policy stated outdated drugs shall not be used and shall be returned to the dispensing pharmacy or destroyed.
The facility's comprehensive assessment was incomplete, lacking documentation of staff involvement, resident population details, and a staffing plan. It also missed information on the physical environment, care requirements, and contingency plans. The administrator acknowledged these deficiencies and was not finished with the necessary modules.
The facility failed to maintain the dignity of two residents. A resident with an indwelling catheter was observed with the catheter bag uncovered, and another resident with severe cognitive impairment was transported in a shower chair without being fully covered. Staff confirmed these observations, and the DON emphasized the importance of maintaining resident dignity.
The facility failed to provide residents access to their personal funds during evenings and weekends, as confirmed by resident interviews and the Business Office Manager. Residents expressed concerns about not having money for the weekend if not obtained by Friday. The facility's policy did not address access to funds during these times.
The facility did not provide quarterly personal funds account statements to residents or their legal representatives, as confirmed by the BOM and Resident Council. The policy on managing personal funds lacked guidance on issuing statements. Additionally, the BOM was unaware of interest accrual limits for Medicaid residents, and several residents had in-house account balances exceeding $50.00, which were not addressed in the facility's policy.
A facility failed to revise a resident's care plan to include monitoring for signs, symptoms, or adverse reactions related to high-risk pain medication. The resident, with dementia and a right artificial hip joint, had multiple physician's orders for pain management, including a pain patch. The DON confirmed the oversight and noted the absence of a facility policy for care plans.
The facility failed to secure hazardous chemicals, as observed by surveyors who found multiple unlocked doors to areas containing cleaning supplies. The DON and Environmental Supervisor confirmed these areas should be locked to prevent resident access. Additionally, an unattended housekeeping cart with a spray bottle was found unlocked due to broken locks.
The facility did not post complete nurse staffing information, as required. A surveyor noted that the staffing log was incomplete, missing the census, staff names, and hours worked. The DON confirmed the logs were incomplete and lacked a staffing policy.
A medication cart was left unlocked and unattended in the hallway by an RN, who entered a resident's room and closed the door. The RN admitted the cart was unlocked, and the DON confirmed that medication carts should be locked when unattended, as per facility policy.
The facility failed to properly store and label food items in the kitchen's refrigerator and freezer, and did not adequately clean the ice machine. Observations revealed undated food packages and containers lacking use-by dates, with one container improperly sealed. The ice machine had yellow residue, indicating insufficient cleaning, contrary to the facility's policy for weekly maintenance.
The facility failed to post proper isolation signage for a resident with COVID-19, leading to confusion about necessary precautions. Additionally, the water management program lacked essential components and consistent implementation, with incomplete documentation and no clear identification of potential Legionella growth areas.
A facility failed to thoroughly investigate an abuse allegation involving a resident with dementia. The resident reported being thrown into a chair by a staff member, but the investigation lacked body audits for non-cognitive residents and witness statements from other residents or staff. The alleged staff member was not removed from all resident care, contrary to the facility's policy.
A facility failed to protect a resident's personal and medical information when an RN left the Medication Administration Record (MAR) open on a medication cart, making it visible to passersby. The resident, who was cognitively intact and had a history of cerebral infarction and depression, had their information exposed due to the RN's inaction. The DON acknowledged that the MAR should have been closed or covered to ensure privacy, as required by the facility's policy on Resident Rights.
A facility failed to update a resident's care plan to include oxygen use, despite physician's orders for oxygen therapy. The resident was observed using an oxygen concentrator, but the care plan did not reflect this need. The DON confirmed the absence of a policy for care plans and stated that updates were made quarterly based on MDS assessments.
A resident was observed receiving oxygen at a flow rate of 2.5 liters per minute, contrary to the physician's order of 2 liters per minute as needed for shortness of breath. The LPN confirmed the discrepancy, and the DON noted that the medication administration record did not specify checking the oxygen flow rate, leading to the administration of oxygen at an incorrect rate.
Expired OTC Medications Found in Active Storage
Penalty
Summary
The facility failed to ensure expired OTC medications were removed from active medication storage and disposed of, as required by facility policy, for one of one OTC medication storage cabinet reviewed. During an observation of the medication storage room, expired unopened OTC medications were found stored with medications in active rotation, including two cough and congestion elixir bottles with a 01/2026 expiration date, two calcium medication bottles with a 09/2025 expiration date, and one acid reducer medication bottle with a 01/2026 expiration date. During interviews, an LPN verified the expired medications were removed from the cabinet and taken to the DON for disposal. The LPN stated that if the DON was not present, nurses would pour expired OTC medications into a sharps container and report them to the DON. The DON stated she ordered and stocked OTC medications and checked expiration dates when stocking, but acknowledged she missed some expired items. She also stated expired OTC medications were disposed of in a sharps container. The facility policy stated discontinued, outdated, or deteriorated drugs shall not be used and shall be returned to the dispensing pharmacy or destroyed.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to ensure that its comprehensive facility assessment included all necessary information to allocate resources and meet the needs of its residents. The assessment, dated November 2017, lacked documentation of the staff involved in its development, including key personnel such as a member of the governing body, the medical director, the administrator, the director of nursing, and direct care staff. Additionally, the assessment did not have an initiated or revision date to indicate a yearly review, nor did it include details about the resident population, the physical environment, equipment, services, and other considerations necessary for resident care. The assessment also failed to address the care required by the resident population using evidence-based, data-driven methods, and did not include a staffing plan to ensure sufficient qualified staff were available to meet residents' needs. Furthermore, it lacked a competency-based skill set approach for staffing decisions, a plan for recruiting and retaining medical personnel, and information on the facility's resources, including buildings, equipment, and services. The facility's health information technology resources and a contingency plan for non-emergency events impacting resident care were also missing. The administrator acknowledged the deficiencies and stated that she was not done completing the necessary modules and was scheduled to attend a meeting on how to complete the facility assessment.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of two residents, as observed by surveyors. Resident #31, who was cognitively intact and had an indwelling catheter, was observed on multiple occasions with the catheter bag uncovered and visible, both in their room and in the hallway. A Certified Nursing Assistant (CNA) confirmed the catheter bag was uncovered and stated it should have been covered. The Director of Nursing (DON) acknowledged the importance of covering indwelling catheters to maintain resident dignity. Resident #21, diagnosed with vascular dementia and severe cognitive impairment, was observed being transported in a shower chair without being fully covered, exposing the right side of their upper thigh. A CNA confirmed the resident was not fully covered during transport. The DON stated that staff should ensure residents are covered down to the knees when being transported from the shower room to maintain dignity. The facility's policy on dignity emphasizes the importance of promoting and protecting resident privacy and prohibits demeaning practices.
Lack of Access to Resident Funds on Weekends
Penalty
Summary
The facility failed to honor residents' rights to manage their financial affairs by not providing access to personal funds during evenings and weekends. During an interview with the Resident Council, residents expressed concerns about their inability to access their trust funds outside of regular business hours. One resident mentioned that if they did not obtain their money by Friday, they would not have funds available for the weekend. Another resident echoed this sentiment, indicating a lack of access to funds during weekends if not obtained during the week. The Business Office Manager confirmed that residents did not receive money on weekends, stating that they must obtain it before the weekend or not at all. Additionally, the facility's policy on the management of residents' personal funds did not address the procedures or timing for accessing these funds, contributing to the deficiency.
Failure to Provide Quarterly Personal Funds Statements and Manage Resident Accounts
Penalty
Summary
The facility failed to provide quarterly personal funds account statements to residents or their legal representatives, as required. During an interview, members of the Resident Council reported not receiving these statements. The Business Office Manager (BOM) confirmed that quarterly statements were not sent out, although they could be printed upon request. The facility's policy on managing residents' personal funds did not address the issuance of quarterly statements. Additionally, the BOM indicated the use of a separate petty cash system for residents' money but was unaware of the maximum amount that could be held without accruing interest for Medicaid residents. A review of the in-house account list revealed that several Medicaid residents had balances exceeding $50.00, with one resident having a balance as high as $211.50. The facility's policy did not cover the management of in-house or petty cash accounts.
Failure to Revise Care Plans for High-Risk Medications
Penalty
Summary
The facility failed to ensure that care plans were revised at least quarterly or when the residents' care needs changed, as evidenced by the case of a resident with dementia and a right artificial hip joint. The resident had multiple physician's orders for pain management, including oral pain medication and a pain patch, which were not adequately reflected in the care plan. Specifically, the care plan did not include monitoring for signs, symptoms, or adverse reactions related to the high-risk pain medication, an opioid, that the resident was taking. During an interview, the Director of Nursing confirmed that the resident had an order for pain patches, which are considered high-risk medications, and acknowledged that the medication should have been care planned to monitor for possible side effects. However, it was revealed that the facility did not have a policy in place for care plans, contributing to the oversight in updating the resident's care plan to address the use of high-risk medications.
Failure to Secure Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that potential hazardous chemicals were securely locked away, as observed by the surveyor. On multiple occasions, the surveyor noted unlocked doors to areas containing cleaning chemicals, such as a janitor's closet, a Whirlpool room, and a closet on the South Hall, all of which were supposed to be locked when not in use. The Director of Nursing confirmed that these areas should be locked to prevent resident access to potentially harmful substances. Additionally, a sign on one of the doors explicitly instructed staff to keep it latched at all times, yet it was found unlatched. Further observations revealed an unattended housekeeping cart with a spray bottle hanging from the handle, which was not locked due to broken locks on the cart. Housekeeping staff confirmed that they could not lock the cart as the keys did not fit. The Environmental Supervisor acknowledged that the doors to the janitor, soiled linen, and Whirlpool rooms, as well as the cart, should be locked to prevent resident access to chemicals. The facility's policy on chemical storage mandates that all doors in designated Environmental Services areas should have locks and restrict access to cleaning staff only.
Incomplete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted accurately and completely, as required. On two separate occasions, a surveyor observed that the staffing log near the entrance was incomplete. On the first occasion, only one name was written on the log. The following day, the Director of Nursing (DON) acknowledged that the staffing log was visible but incomplete, lacking the census and the names of all staff members working at the time. Additionally, the log did not include the total number of hours worked and actual hours per shift for both licensed and unlicensed staff. The DON confirmed that previous days' logs were similarly incomplete and that the facility did not have a policy and procedure on staffing documentation.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely locked away, as observed by a surveyor. On the morning of September 11, 2024, a Registered Nurse (RN) left a medication cart unattended and unlocked in the hallway while entering a resident's room and closing the door. The RN acknowledged that the cart was unlocked and admitted that someone could have accessed the medications. The Director of Nursing (DON) confirmed that nurses are required to lock medication carts before leaving them unattended, as per the facility's policy on the storage of medications. This policy mandates that compartments containing drugs and biologicals must be locked when not in use, and carts used for transporting these items should not be left unattended if open or accessible to others.
Deficiencies in Food Storage and Ice Machine Cleaning
Penalty
Summary
The facility failed to ensure proper storage and labeling of food items in the kitchen's refrigerator and freezer, as well as adequate cleaning of the ice machine. During an inspection, it was observed that the freezer contained packages of pancakes without dates and a piece of toast in a bag with an unclear date. The refrigerator had a bag of cooked hamburger meat and containers of black-eyed peas and pork loin, all lacking clear use-by dates. The pork loin container was not properly sealed, and the Dietary Manager confirmed the absence of use-by dates on these items, contrary to the facility's policy requiring food to be labeled and dated, with leftovers discarded after 72 hours. Additionally, the ice machine in the kitchen was found to have a yellow residue on the area where ice falls, indicating inadequate cleaning. The Dietary Manager, upon inspection, confirmed the presence of the residue and stated that maintenance cleans the ice machine annually, despite the facility's policy requiring weekly cleaning of the ice storage compartment. These observations highlight a failure to adhere to established food storage and equipment cleaning protocols, as outlined in the facility's policies.
Deficiencies in Isolation Signage and Water Management Program
Penalty
Summary
The facility failed to ensure proper isolation signage was posted to alert staff, residents, and visitors of the necessary precautions for a resident who tested positive for COVID-19. During the survey, it was observed that the resident's door lacked appropriate signage indicating contact or droplet precautions, despite the resident being on respiratory precautions. The resident was seen sitting in the doorway without a mask, and there was no clear indication of the required personal protective equipment (PPE) for staff and visitors. Interviews with staff, including a Licensed Practical Nurse and the Infection Preventionist, revealed inconsistencies in the understanding and implementation of isolation protocols. Additionally, the facility's water management program was found to be lacking in necessary components and consistent implementation. The Maintenance Supervisor provided a Legionella Water Management Program policy and a water flow diagram, but there was no comprehensive documentation of water temperatures or identification of potential Legionella growth areas. The water temperature logs were incomplete, lacking details on where temperatures were taken and failing to include critical areas such as hot water heaters and sinks. The Administrator was unable to provide additional information regarding the water management program, including team members, potential Legionella growth areas, or control measures in case of an outbreak. The policy reviewed did not include a date for review or updates, indicating a lack of oversight and adherence to the necessary elements for a comprehensive water management program.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with moderate cognitive impairment and a diagnosis of dementia. The incident report indicated that the resident's feelings were hurt, and they were allegedly thrown into a chair by a staff member. Although the resident was examined and found to have no bruises, they were crying and reassured that the incident would be investigated. However, the investigation was incomplete as there were no body audits conducted on non-cognitive residents on the hall, and no witness statements were obtained from other cognitive residents or staff members. Additionally, there was no in-service conducted on abuse with the staff members following the incident. The Director of Nursing (DON) confirmed that the investigation process was not fully adhered to, as the alleged staff member was not removed from all resident care, only from the alleged victim's care, pending the investigation. The DON also stated that she was unsure if other staff members or cognitively intact residents were interviewed. Furthermore, the facility's Abuse/Neglect Policy and Procedure, which was reviewed, indicated that any individual suspected of resident abuse should be placed on administrative leave without pay and banned from returning to the facility during the investigation, which was not followed in this case.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility failed to protect the personal and medical information of a resident, identified as Resident #14, who was cognitively intact and had a history of cerebral infarction and depression. During an observation, a surveyor noted that a Registered Nurse (RN) left the Medication Administration Record (MAR) open on the medication cart, displaying the resident's personal and medical information. This occurred when the RN entered the resident's room and closed the door, leaving the MAR visible to anyone passing by. The Director of Nursing (DON) confirmed that the MAR should have been closed or covered to prevent unauthorized access to the resident's information. The facility's policy on Resident Rights includes the guarantee of privacy and confidentiality, which was not upheld in this instance.
Failure to Update Care Plan for Oxygen Use
Penalty
Summary
The facility failed to ensure that a comprehensive plan of care was updated to include the use of oxygen for a resident who was reviewed for oxygen use. On a specific date, the resident was observed with an oxygen concentrator set at 2.5 liters per minute, while the physician's orders indicated oxygen at 2 liters per nasal cannula as needed for shortness of breath. However, the resident's plan of care, reviewed on a previous date, did not include any indication of oxygen use. The Director of Nursing confirmed that the facility did not have a policy for care plans and stated that care plans were updated quarterly based on the Minimum Data Set assessments, which should trigger what needs to be care planned.
Failure to Administer Oxygen at Ordered Flow Rate
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician's ordered flow rate for a resident, which could potentially lead to respiratory complications. On two separate occasions, the resident was observed sitting in a recliner with a nasal cannula, and the oxygen concentrator was set at 2.5 liters per minute, despite the physician's order specifying 2 liters per minute as needed for shortness of breath. The resident's Minimum Data Set indicated they were moderately cognitively intact and received oxygen therapy, but the Resident Plan of Care did not include oxygen use. During an interview, an LPN confirmed the discrepancy in the oxygen flow rate and stated that the nurse on shift was responsible for checking the rate once a day. However, the Director of Nursing later indicated that the medication administration record did not specify that the oxygen flow rate should be checked for accuracy. This oversight in documentation and monitoring led to the administration of oxygen at an incorrect flow rate, contrary to the physician's orders.
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What surveyors actually found near you
We read the 3 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near De Witt
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestpark Dewitt, Llc | 0.8 mi | ★★★★★ | 3 | 0 |
| Crestpark Stuttgart, Llc | 18.7 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Star City Rehab & Nursing Center | 37 mi | ★★★★★ | 0 | 0 |
| Oak Grove Retirement Home | 37.9 mi | ★★★★★ | 5 | 0 |
| Maple Healthcare | 38 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.