Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Hewitt Health & Rehabilitation Center, Inc during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities exhibited new, escalating behavioral symptoms including anger and agitation, but staff did not notify the provider or nursing supervisor as required by facility policy. Instead, the behaviors were only documented in a psychiatric APRN book, delaying appropriate assessment and intervention. Staff interviews confirmed that the provider should have been notified of the significant change in condition.
The facility did not provide adequate nursing staff coverage on weekends for two consecutive quarters, as shown by PBJ data and confirmed by staff interviews. Staffing challenges were attributed to frequent call-outs and retention issues, resulting in the facility triggering for low weekend staffing during the review period.
The facility did not consistently complete or document advance directives for several residents, resulting in missing or unsigned consent forms and delays in obtaining code status orders. In some cases, residents' choices for life-sustaining treatment were not properly recorded or accompanied by physician orders, and staff interviews revealed inconsistent processes for reviewing and documenting advance directives.
The facility did not notify resident representatives or physicians of significant weight loss or gain in several residents, despite clear evidence of these changes and requirements in care plans, physician orders, and facility policy. Staff interviews and record reviews confirmed that notifications were not made or documented, resulting in a failure to communicate important changes in resident condition.
Surveyors found that the facility did not complete timely smoking assessments, failed to supervise residents during smoking, and did not secure smoking materials as required by policy. Multiple residents with significant medical conditions were observed smoking unsupervised on facility property, possessing lighters and cigarettes, and sharing smoking materials, while staff were unclear about their responsibilities for securing these items.
A resident with severe cognitive impairment and a seizure disorder was given Lorazepam by an LPN for agitation and insomnia, despite the medication being ordered only for seizures. The LPN, after consulting with the nursing supervisor, administered the medication without obtaining a new physician order and documented it under the existing seizure order, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions was found with significant bruising and swelling on the right upper extremity, identified as an injury of unknown origin. Although facility policy required prompt reporting to the State Agency, the DNS delayed notification while investigating the incident, resulting in the injury not being reported within the mandated timeframe.
Two residents did not receive timely RN assessments after significant events, including the discovery of a new pressure ulcer and a fall. In both cases, LPNs either did not notify the RN supervisor or failed to ensure proper documentation, resulting in missed assessments as required by facility policy.
A resident who was dependent on staff for ADLs and had significant physical and cognitive impairments was found to have lengthy, unclean fingernails with a dark substance underneath, despite facility policies and care plans requiring regular nail care. Multiple staff members observed the issue but did not address it, citing being too busy or unclear responsibilities, resulting in the resident's hygiene needs not being met.
A resident with heart failure and related conditions was not weighed daily as ordered by the physician, with 38 missed weights over a period of several months. Both an LPN and the DON confirmed that daily weights were not consistently obtained or documented, despite the care plan and facility policy requiring adherence to physician orders.
A resident with a stage 3 sacral pressure ulcer did not receive wound care in accordance with physician orders, as an LPN attempted to use an incorrect dressing and failed to follow proper hand hygiene. Additionally, the frequency of dressing changes was incorrectly transcribed from the wound APRN's recommendations, resulting in care that did not match the prescribed treatment plan.
A nurse failed to administer ordered doses of Aspirin and Miralax to a resident with dementia and a history of blood clots, but documented in the MAR that the medications were given. This omission led to a medication error rate above 5%, as required medications were not provided and documentation was inaccurate.
Staff failed to follow PPE and hand hygiene protocols during wound care for two residents on enhanced barrier precautions. In one case, an LPN did not wear an isolation gown as required, and in another, both an LPN and a nurse aide did not perform hand hygiene before donning PPE or between glove changes, despite facility policies and posted signage. These actions resulted in noncompliance with the infection prevention and control program.
The facility did not complete required Significant Change in Status Assessments (SCSA) MDS for two residents who experienced declines in multiple health areas, including new or worsening pressure ulcers, significant weight loss, and increased dependence for ADLs. Staff interviews revealed a lack of understanding of SCSA criteria and insufficient communication among the interdisciplinary team, resulting in missed assessments despite documented changes.
A resident with diabetes, anxiety, and depression did not receive a required quarterly care conference after the originally scheduled meeting was postponed due to the resident being out of the building. Staff interviews confirmed the meeting was not rescheduled as required, and no facility policy on care conferences was provided.
A medication storage refrigerator was repeatedly documented as being out of the required temperature range, with temperatures below the facility's policy for safe medication storage. The refrigerator contained various medications, and staff responsible for monitoring temperatures were unaware of the ongoing issue. Maintenance and supervisory staff were not notified as required, and temperature logs for the previous year were not provided, indicating lapses in documentation and adherence to policy.
A resident with severe cognitive impairment and a history of falls suffered a significant leg laceration during a transfer when Geri-leg sleeves, ordered by the physician to prevent skin injury, were not confirmed to be in place. Staff interviews and documentation could not verify if the protective sleeves were applied at the time, leading to the resident's leg becoming caught on a bed rail and requiring sutures and steri-strips.
A resident with Alzheimer's and depression experienced increased anxiety and agitation after a change in Ativan dosage was not properly communicated to the pharmacy, resulting in multiple missed doses. Nursing staff did not follow up with the provider or pharmacy when the medication was unavailable, and the resident's behaviors escalated, requiring additional interventions and hospitalization. Interviews revealed a lack of clarity among staff regarding responsibility for ensuring medication orders were processed and followed up.
A resident with dementia and mood disorders reported to an LPN that a nurse aide had caused them harm by pulling a phone from their hand and hitting their shoulder. The LPN did not remove the nurse aide from care or report the allegation immediately, allowing the aide to continue providing care. The incident was only escalated after the resident called 911, and the supervisor was not informed until the aide had left the building, contrary to facility policy.
Two residents with significant fall risks and orders for assistive transfers experienced falls with injuries when staff failed to use gait belts during transfers and ambulation, as required by facility policy. In both cases, staff did not follow the mandatory gait belt protocol, resulting in one resident sustaining a femur fracture and another requiring staples for a head laceration.
Failure to Notify Provider of Resident's Change in Behavior
Penalty
Summary
A deficiency occurred when staff failed to notify the provider of a resident's significant change in behavioral symptoms. The resident, who had diagnoses including dementia with behavioral disturbances, anxiety, major depressive disorder, emphysema, and congestive heart failure, exhibited new and escalating angry outbursts and agitation over several days. These behaviors included throwing linens, screaming at staff, and throwing fluids, which were not part of the resident's documented baseline behavior. Despite these changes, there was no evidence that the nursing supervisor or provider were notified at the time the behaviors were first observed. The clinical record review showed that prior to these incidents, the resident had not exhibited similar angry outbursts. Staff attempted to redirect the resident but did not escalate the issue or seek provider input, even though the resident was unable to be redirected and had no available as-needed medication to address the agitation. The behaviors were only documented in a psychiatric APRN book, with no immediate notification to supervisory staff or the provider, contrary to facility policy which required provider notification for significant changes in condition. Interviews with staff confirmed that the provider should have been notified of the resident's behavioral changes, as these were not consistent with the resident's baseline and could have indicated an underlying medical issue. The delay in notification meant that potential interventions, such as ordering laboratory tests or adjusting medications, were not initiated in a timely manner. Facility policy also required documentation of provider and family notification, which was not completed at the time of the initial behavioral changes.
Deficiency in Weekend Nursing Staff Coverage
Penalty
Summary
The facility failed to provide the appropriate number of nursing staff on weekends during Quarter 1 and Quarter 2 of Fiscal Year 2024, as evidenced by Payroll Based Journal (PBJ) submissions that triggered for excessively low weekend staffing. Interviews revealed that the Scheduler was not responsible for PBJ submissions and was unaware of the low staffing trigger, while the HR coordinator, who is currently responsible for PBJ submissions, was not employed at the facility during the period in question. The Scheduler reported that weekend staffing was a challenge due to frequent call-outs by nursing and agency staff, as well as issues with staff retention. The VP of Clinical Operations confirmed awareness of the low weekend staffing during the specified quarters. The facility's policy manual requires complete and accurate electronic submission of direct care staffing information to CMS, and notes that noncompliance may result in enforcement actions. The deficiency was identified through review of PBJ data and staff interviews, which confirmed that the facility did not meet required weekend staffing levels during the specified timeframe.
Failure to Consistently Complete and Document Advance Directives
Penalty
Summary
The facility failed to follow its own policy regarding the completion and documentation of residents' advance directives for four residents. In multiple cases, the required Medical Interventions Consent Form, which records a resident's choices for life-sustaining treatments and other medical interventions, was either missing from the clinical record or not signed by the resident or their representative. For example, one resident with diagnoses including paranoid schizophrenia and kidney cancer, who was cognitively intact, did not have a completed or signed consent form in the record, despite a physician order indicating CPR as the code status. Similarly, another resident with dementia and chronic kidney disease, who was moderately cognitively impaired, also lacked a signed consent form, even though a physician order for CPR was present. In another instance, a resident with severe cognitive impairment and multiple diagnoses had a Medical Interventions Consent Form completed by a representative via telephone, indicating comfort measures only and do-not-resuscitate/do-not-intubate status. However, after a psychiatric hospitalization and re-admission, there was a period during which no physician order for advance directives was present in the clinical record. Staff interviews revealed that the process for obtaining and documenting advance directives was inconsistent, with responsibilities split between nursing supervisors and social workers, and follow-up with representatives sometimes limited to leaving phone messages. Additionally, a resident admitted with sepsis, heart failure, and endocarditis, who was cognitively intact, did not have a code status order in place for eight days after admission. During this time, the resident would have been classified as full code and provided CPR by default. Staff interviews confirmed that code status should be established upon admission, and that verbal consent could be obtained if the resident was unable to sign. The facility's policy required that advance directives be reviewed with the resident or representative, documented on the consent form, and accompanied by a physician order, but these steps were not consistently followed.
Failure to Notify Responsible Parties and Physicians of Significant Weight Changes
Penalty
Summary
The facility failed to notify resident representatives and physicians of significant weight changes in multiple residents, as required by policy and physician orders. For three residents with cognitive impairment and designated representatives, there was no documentation that the responsible party was informed of substantial weight loss, despite clear evidence in the clinical record and dietician notes of weight declines exceeding 5% in one month or 10% in six months. In each case, the care plans and facility protocols required notification, and staff interviews confirmed that nurses were responsible for this communication, yet the notifications were not documented. One resident with congestive heart failure had physician orders specifying that the physician should be notified of a weight gain of 3 pounds in 24 hours or 5 pounds in one week. Despite documented weight gains meeting these criteria, there was no evidence that the physician was notified. Staff interviews confirmed awareness of the protocol and the expectation to notify the physician, but could not provide documentation that this occurred. The facility's heart failure protocol and weight monitoring policy both required timely reporting of significant weight changes to the physician and family. The deficiency was identified through review of clinical records, facility documentation, and staff interviews. The lack of notification was confirmed by the absence of progress notes or other documentation in the electronic medical record, as well as direct statements from staff that notifications had not been made. The facility's own policies and protocols, as well as physician orders, were not followed in these instances, resulting in a failure to communicate significant changes in resident condition to the appropriate parties.
Failure to Supervise and Secure Smoking Materials for Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents related to resident smoking. For three residents reviewed for smoking, there were multiple failures including untimely completion of smoking assessments, lack of supervision during smoking, and failure to secure smoking materials as required by the residents' care plans and facility policy. Observations showed residents smoking unsupervised on facility property, possessing lighters and cigarettes despite policies prohibiting such items, and sharing smoking materials with other residents. One resident with end stage heart failure, asthma, and a left leg amputation was observed smoking outside the facility unsupervised on several occasions. Although the resident's care plan required that smoking materials be secured by nursing staff and that the resident not possess such items, the resident was found with a lighter in their possession and admitted to purchasing and keeping smoking materials. Interviews with staff revealed confusion and lack of clarity regarding who was responsible for securing smoking materials, with both nursing and front desk staff denying responsibility. Smoking assessments for this resident were not completed quarterly as required, and the resident was observed repeatedly smoking on facility property without supervision. Two other residents with histories of smoking and medical conditions such as diabetes, falls, osteoarthritis, substance abuse, and acute kidney failure were also found to have incomplete or delayed smoking assessments. One resident did not have a smoking assessment completed upon admission, and another had only one assessment completed months after admission. Both residents were observed smoking on facility property, sometimes sharing lighters, and staff interviews indicated a lack of awareness about the residents' smoking status and the location of their smoking materials. Facility policy required completion of smoking assessments on admission and securing of smoking materials, but these procedures were not consistently followed.
Psychotropic Medication Administered Without Proper Physician Order
Penalty
Summary
A resident with diagnoses including autistic disorder, developmental disorder, and unspecified convulsions was admitted with severe cognitive impairment and required significant assistance with daily activities. The resident's care plan included administration of medications as ordered for a seizure disorder. A physician's order specified Lorazepam 1 mg by mouth every 24 hours as needed for seizures. However, on one occasion, Lorazepam was administered by an LPN for agitation and insomnia, not for seizures as indicated by the physician's order. The LPN consulted with the nursing supervisor, who authorized the administration despite the absence of a seizure and without obtaining a new physician order for agitation or insomnia. The LPN documented the administration of Lorazepam under the existing order for seizures, even though the medication was not given for that purpose. The nursing supervisor attempted to contact the physician for a new order but was unsuccessful and still permitted the medication to be given. Both the LPN and the nursing supervisor later acknowledged that Lorazepam should not have been administered for agitation or insomnia without a valid physician order. Facility policy requires that all medications be administered only with a valid physician's order and in accordance with facility protocols.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A resident with diagnoses including dementia, anemia, and non-thrombocytopenic purpura, who was severely cognitively impaired and dependent for care, was observed to have a large area of bruising and swelling on the right upper extremity. The injury, which included a skin tear and discoloration from the hand to the elbow, was first noted by staff, and the physician and family were notified. Facility documentation indicated that the injury was of unknown origin, and an investigation was not initiated at the time of discovery. Despite facility policy requiring prompt reporting of injuries of unknown origin to the State Agency (SA) within the required time frame, the Director of Nursing Services (DNS) did not report the injury to the SA while the investigation was ongoing. The DNS acknowledged responsibility for timely reporting but cited workload as a reason for the delay. The injury was ultimately reported to the SA several days after it was first identified, outside of the required reporting window.
Failure to Complete Required RN Assessments After Resident Incidents
Penalty
Summary
The facility failed to ensure that Registered Nurse (RN) assessments were completed following significant events for two residents. In the first case, a resident with dementia, fibromyalgia, and anxiety, who was at risk for skin breakdown, was found to have a new open area on the coccyx by an LPN. The LPN documented cleansing and dressing the wound and noted that the nursing supervisor was notified to obtain a treatment order. However, there was no subsequent RN assessment documented in the electronic medical record, as required by facility policy. The RN supervisor on duty did not recall being informed of the new pressure ulcer, and there was no evidence of an accident and injury report being completed for this event. In the second case, a resident with a history of femur fracture, autistic disorder, and seizures, who required assistance with mobility and transfers, was found on the floor by a family member. The LPN on duty, along with three other staff, assisted the resident off the floor and back into bed. The LPN did not inform the RN supervisor of the fall, citing the end of her shift and inability to locate the RN. As a result, the required RN assessment after the fall was not completed, and the resident was not assessed by an RN until the following day by an APRN. Facility policy required an RN assessment after any fall or significant change in condition, which was not followed in this instance. Both incidents demonstrate a failure to adhere to facility policies that mandate RN assessments following significant changes in resident condition, such as new pressure ulcers or falls. The lack of timely RN assessments and documentation after these events constituted deficiencies in meeting professional standards of quality care for the residents involved.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, dementia, and end stage renal disease was observed to have lengthy and unclean fingernails with a dark brown substance underneath. The resident was severely cognitively impaired and dependent on staff for activities of daily living, including personal hygiene and nail care. Facility documentation and care plans indicated that the resident required total assistance with bathing and nail hygiene, and that nail care was to be performed weekly during scheduled showers. Despite these requirements, multiple observations over several days revealed that the resident's fingernails remained untrimmed and unclean, with one lengthy thumbnail pressing into the side of another finger on a contracted hand. Interviews with nursing staff and nurse aides revealed that nail care was not consistently provided due to staff being too busy or unclear about responsibility for the task. Nurse aides acknowledged seeing the resident's long and dirty nails and reported the issue to nursing staff, but did not address it during their shifts. The Director of Rehab confirmed that the resident was unable to perform nail care independently and that nursing staff had been informed of the need for regular nail maintenance due to the risk of skin breakdown. Facility policy required individualized assistance with daily care, including nail hygiene, but this was not followed for the resident in question.
Failure to Obtain Daily Weights as Ordered for Resident with Cardiac Conditions
Penalty
Summary
A deficiency was identified when a resident with diagnoses including congestive heart failure, pleural effusion, and cardiomyopathy was not weighed daily as ordered by the physician. The resident's care plan included daily weights as an intervention for cardiac risk, and a physician order dated 12/1/24 specified daily weights. However, review of the weight record from 12/1/24 to 5/15/25 showed that daily weights were missed on 38 out of 166 occasions. Interviews with an LPN and the Director of Nursing confirmed that the resident was not weighed daily according to the physician's order and that it was the nurse's responsibility to obtain and document the daily weight. The facility's weight monitoring policy required weights to be taken as ordered by the physician, but this was not consistently followed for the resident in question.
Failure to Provide Pressure Ulcer Care per Physician Orders and Accurate Transcription
Penalty
Summary
A deficiency was identified in the care of a resident with a stage 3 sacral pressure ulcer, who also had diagnoses of muscle weakness and osteomyelitis. The resident required substantial to maximal assistance for activities such as dressing, toileting, and repositioning in bed. The care plan specified that wound treatments should be administered as ordered and in accordance with facility protocols. However, during an observed wound treatment, an LPN failed to follow proper hand hygiene protocols and attempted to use a collagen matrix dressing instead of the physician-ordered calcium alginate with silver dressing. The LPN incorrectly believed the two dressings were interchangeable, but the Infection Prevention Nurse clarified that they were not, and the correct dressing was subsequently applied after intervention. Additionally, a review of the resident's wound care orders revealed that the frequency of dressing changes was incorrectly transcribed. The wound APRN had recommended dressing changes twice daily, but the order was entered as once daily. This transcription error was confirmed by the Infection Prevention Nurse, who was responsible for transcribing the recommendations. The facility's policies required that physician orders be complete and accurate, and that treatments be performed as ordered, but these requirements were not met in this instance.
Medication Error Rate Exceeds 5% Due to Omitted Doses and Inaccurate MAR Documentation
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications as ordered to a resident with diagnoses including dementia, atrial fibrillation, and a history of venous thrombus and embolism. The resident, who was severely cognitively impaired and required significant assistance with daily activities, had physician orders for Aspirin EC 81mg once daily for atrial fibrillation and Miralax 17 grams twice daily for constipation. During a medication administration observation, the nurse prepared and dispensed all scheduled oral medications except for the Aspirin and Miralax, which were omitted from the administration. Despite not administering these medications, the nurse signed the Medication Administration Record (MAR) indicating that both Aspirin and Miralax had been given. The nurse later acknowledged that she had forgotten to administer the medications and had signed the MAR in error. Facility policy requires that all medications be administered safely and accurately in accordance with physician orders, and the omission resulted in a medication error rate of 7.14%, exceeding the acceptable threshold.
Failure to Follow PPE and Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene during wound care for two residents on enhanced barrier precautions (EBP). For one resident with dementia, anemia, and venous/arterial ulcers, an LPN provided wound care without donning an isolation gown, despite EBP signage and care plan interventions requiring both gown and gloves for wound treatment. The LPN acknowledged not wearing the gown and was unaware it was required, even though training and signage were present. In a separate incident, another resident with a stage 3 pressure ulcer and osteomyelitis received wound care from staff who did not perform hand hygiene before donning PPE or between glove changes, as required by facility policy. During the wound care procedure, the LPN changed gloves without hand hygiene and applied a new glove with a contaminated hand, while the nurse aide also failed to perform hand hygiene before applying PPE. Both staff members were unable to clearly articulate the correct hand hygiene protocol during interviews. Facility policies for EBP and hand hygiene direct staff to perform hand hygiene before and after resident care, before donning PPE, and between glove changes, especially during high-contact activities such as wound care. Observations and interviews confirmed that these protocols were not followed during the wound care of both residents, resulting in a failure to implement the infection prevention and control program as required.
Failure to Complete Significant Change MDS Assessments After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for two residents who experienced declines in multiple areas of health status. For one resident with dementia and a history of pressure ulcers, the clinical record showed a new Stage 2 pressure ulcer, a decline in functional mobility, and significant weight loss over several months. Despite these changes, which included increased assistance needs for eating, bed mobility, and transfers, as well as the development and worsening of pressure ulcers, no SCSA MDS was completed as required. Another resident with early onset Alzheimer's disease, diabetes, and epilepsy experienced a hospitalization for altered mental status and subsequently returned to the facility with increased dependence on staff for activities of daily living (ADLs) and eating. This resident also had a notable weight loss following hospitalization and required more assistance with meals. The quarterly MDS assessment documented declines in four functional mobility areas and weight loss, but again, a significant change MDS was not completed. Interviews with facility staff revealed a lack of understanding regarding the criteria for initiating a significant change MDS assessment. One LPN indicated she was unaware that weight loss plus a decline in one ADL met the criteria for a significant change, and that she relied on the dietician to code weight loss in the MDS. The facility's interdisciplinary team, including the dietician and nursing staff, did not effectively communicate or recognize the need for a significant change assessment despite regular risk meetings and documentation of the residents' declines.
Quarterly Care Conference Not Rescheduled After Postponement
Penalty
Summary
The facility failed to conduct a quarterly care conference for one resident whose diagnoses included diabetes, anxiety, and depression. The resident was identified as cognitively intact and independent in activities of daily living. According to the clinical record, the resident's care plan addressed risks related to mood changes and included interventions for emotional support. The quarterly care conference was scheduled but postponed because the resident was out of the building on a leave of absence, and the meeting was not rescheduled. Interviews with facility staff confirmed that the required care conference did not occur within the expected timeframe and that this was due to an oversight. No facility policy on care conferences was provided when requested.
Failure to Maintain Proper Medication Refrigerator Temperatures and Documentation
Penalty
Summary
The facility failed to maintain proper refrigerator temperatures for medication storage in one of its medication storage rooms. Observations and temperature logs revealed that the medication refrigerator on Unit 1C was repeatedly documented as being out of the required temperature range on multiple dates, with recorded temperatures between 28°F and 32°F, which is below the facility's stated acceptable range of 36°F to 46°F. The refrigerator contained various medications, including insulin products, suppositories, ophthalmic solution, and intravenous medications. Staff interviews indicated that the responsibility for monitoring and documenting refrigerator temperatures fell to the overnight nurse, but there was a lack of awareness among staff and supervisors regarding the out-of-range readings. The Maintenance Director was not notified of the temperature issues, and the Director of Nursing Services was also unaware of the ongoing problem. Review of facility policy and interviews further revealed inconsistencies in the understanding of acceptable temperature ranges and the required actions when temperatures were out of range. The policy required notification of maintenance and the supervisor on duty if temperatures were not within the specified range, but this was not consistently followed. Additionally, temperature logs for the previous year were not provided upon request, indicating a lack of proper documentation and oversight in medication storage practices.
Failure to Apply Geri-Legs as Ordered Results in Resident Leg Laceration
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's Disease, dementia, psychotic disorder, muscle weakness, and a history of falls did not have Geri-leg sleeves applied as ordered by the physician. The physician's order specified that Geri-legs should be applied in the morning and removed at night to prevent skin impairment. The resident's care plan also included this intervention due to the risk for skin impairment and required gentle handling during transfers. Despite these orders, during a transfer from wheelchair to bed, the resident's left lower leg became caught on the bed rail, resulting in a three-inch laceration that required sutures and steri-strips. Documentation and interviews with staff, including the nurse aide, LPN, and DON, revealed that none could confirm whether the Geri-legs were in place at the time of the incident. The resident was identified as having severe cognitive impairment and required extensive assistance with transfers. The incident was reported after the nurse aide noticed bleeding during the transfer, and the resident was subsequently sent to the emergency department for treatment. The facility's staff, including the DON, acknowledged that the expectation was for the Geri-legs to be applied if there was a physician's order, but could not verify compliance at the time of the accident. This failure to ensure the application of Geri-legs as ordered contributed to the resident sustaining a significant leg laceration during routine care.
Failure to Ensure Timely Communication and Administration of Changed Medication Order
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a change in an anti-anxiety medication order for a resident with Alzheimer's Disease and depression was properly communicated to the pharmacy and followed up by staff, resulting in multiple missed doses. The resident had a care plan identifying the risk for adverse effects from psychotropic drugs and required close monitoring of mood and behavior. A new order was written to change the Ativan dosage and schedule, but the prescription was not sent to the pharmacy in a timely manner, and staff did not follow up when the medication was unavailable. Nursing notes documented that the resident exhibited increased anxiety, agitation, and aggressive behaviors after the medication change, with several scheduled doses of Ativan not administered because the medication was not available. Staff failed to notify the provider or ensure the pharmacy was contacted regarding the unavailability of the medication. The resident's behaviors escalated, leading to interventions such as one-to-one observation and, eventually, transfer to the hospital. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for ensuring the prescription was sent to the pharmacy and for following up when the medication was not available. The facility's policy required staff to review medication orders and follow up with the pharmacy, but this was not done. The pharmacy confirmed that the new prescription was not received until several days after the order was written, resulting in missed doses and unaddressed behavioral symptoms.
Failure to Remove Staff After Abuse Allegation
Penalty
Summary
A deficiency occurred when a resident with vascular dementia, anxiety, and depression reported to an LPN that a nurse aide had treated them badly, including pulling a phone from their hand, causing pain to their fingers, and hitting their right shoulder. The LPN, after being informed of the alleged abuse, allowed the nurse aide to continue providing care to the resident and did not immediately report the allegation to the Nursing Supervisor as required by facility policy. The resident subsequently called 911, and EMS was dispatched to the facility. Facility documentation, including a video timeline, confirmed that the nurse aide continued to enter and exit the resident's room after the allegation was made and after the facility was notified by 911 dispatch. Interviews with the DON and Nursing Supervisor revealed that the supervisor was not made aware of the allegation until after the nurse aide had left the building. The facility's abuse policy requires immediate reporting and removal of staff from resident care following an allegation, which was not followed in this instance.
Failure to Use Gait Belts During Transfers and Ambulation
Penalty
Summary
The facility failed to ensure the use of a required safety device, specifically a gait belt, during transfers and ambulation for two residents with significant fall risks and physician orders for assistance. In both cases, the residents had multiple risk factors for falls, including dementia, osteoporosis, deconditioning, unsteady gait, and poor safety awareness. Despite care plans and physician orders specifying the need for assistive devices and staff assistance, staff did not utilize a gait belt during transfers, contrary to facility policy. One resident experienced a witnessed fall during a transfer from the toilet when their leg gave out, resulting in a displaced femur fracture. The staff member involved admitted to not using a gait belt because it was lost. Another resident, with a history of falls and fractures, fell in the bathroom after using the toilet and struck their head, requiring hospital evaluation and staples for a laceration. In both incidents, fall scene investigations confirmed that gait belts were not used, and staff interviews corroborated the lack of adherence to the facility's mandatory gait belt policy.
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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 Shelton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apple Rehab Shelton Lakes | 1.2 mi | ★★★★★ | 4 | 0 |
| Gardner Heights Health Care Center, Inc | 1.8 mi | ★★★★★ | 5 | 0 |
| Masonicare At Bishop Wicke Health & Rehabilitation | 2.1 mi | ★★★★★ | 14 | 0 |
| Lord Chamberlain Nursing & Rehabilitation Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Lord Chamberlain Manor Nursing & Rehabilitation Ce | 4.5 mi | ★★★★★ | 5 | 1 |
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