Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was left with a soiled washcloth and a full urinal on the bedside table for several hours after requesting assistance. The responsible CNA failed to return to remove the items, and interviews with staff confirmed this was not in line with facility infection control policies, resulting in a lapse in maintaining a safe and sanitary environment.
A resident with multiple medical conditions and an NPO order did not have required documentation completed in the MAR by an LVN during overnight shifts. The DON and ADM confirmed that the lack of signature indicated the task was not performed, and facility policy requires all care and treatments to be documented with staff signatures.
A resident with multiple medical conditions did not receive timely physical and occupational therapy services due to the facility's failure to submit a completed and accurate PASARR specialized services request in the LTC Online Portal within the required timeframe. Errors and late submissions by the MDS-RN led to repeated rejections and a delay in the resident accessing Medicaid Entitled Services as recommended by the PASARR evaluation.
Two residents with severe cognitive impairment and high dependence on staff were found with their call lights out of reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed awareness of the need for call lights to be within reach, but observations showed that both residents could not access their call lights and had to call out for assistance instead.
A resident with diabetes was inaccurately coded on the MDS as receiving insulin and injections, despite no physician orders or evidence of such treatment. The resident, who was cognitively intact and managed her diabetes without insulin, confirmed she had never received insulin. Staff interviews revealed uncertainty about the resident's treatment history, and the error led to an inaccurate assessment that could affect facility reimbursement.
A resident with a history of thyroid cancer and hypothyroidism did not receive her prescribed Levothyroxine for an unknown period, leading to elevated TSH levels and symptoms such as fatigue, dizziness, and depression. The facility failed to administer the medication as ordered, resulting in a significant change in the resident's condition. Staff interviews revealed a lack of awareness about the missed doses, and the resident expressed a loss of trust in the nursing staff.
A resident with hypothyroidism did not receive her prescribed Levothyroxine medication for an unspecified period, leading to elevated TSH levels and symptoms such as fatigue, dizziness, and depression. The facility's failure to administer the medication as ordered was identified as an Immediate Jeopardy situation. Interviews and record reviews revealed discrepancies in the medication administration records, and the resident's NP confirmed the correlation between missed medication and the resident's deteriorating condition.
A facility failed to provide appropriate care for residents with incontinence and indwelling catheters, leading to deficiencies in preventing UTIs. A resident's Foley catheter was not changed promptly after a UTI diagnosis, and her drainage bag was found on the ground. Two residents did not receive proper incontinent care, with staff failing to clean or change gloves. Another resident's catheter care lacked infection control practices, with staff reusing wipes and not donning PPE. These actions violated the facility's infection control policies.
A resident with increased confusion and altered mental status experienced a delay in urine analysis collection due to a shortage of specimen cups at the facility. The STAT UA ordered by the physician was not collected until several days later, leading to a late diagnosis of a UTI. Interviews revealed a lack of communication among staff regarding the shortage, and the facility's policy for timely test processing was not followed.
A resident with cerebral palsy and quadriplegia developed red areas on the buttocks, with one area opening and causing pain. The facility failed to obtain timely wound care orders, delaying communication with the wound care nurse and physician. This inaction risked improper wound management and potential complications, as staff did not adhere to the facility's skin management policy.
A facility failed to maintain proper infection control during peri care for a resident with severe cognitive impairment and a history of UTIs. Two CNAs did not follow hand hygiene protocols, reused wipes, and failed to change gloves between tasks, contrary to the facility's Perineal Care Policy. This placed residents at risk for cross-contamination and infection spread.
Two residents requiring BiPAP and CPAP therapy did not receive proper respiratory care, as their equipment was not cleaned or maintained according to professional standards. One resident experienced multiple hospitalizations due to respiratory distress, with observations revealing dirty filters and incorrect machine settings. The facility lacked replacement filters, and staff inaccurately documented equipment maintenance, placing residents at risk for infection and respiratory issues.
The facility's dietary services failed to properly reseal, label, and date food items in the walk-in refrigerator and freezer, as observed during a survey. Bags of ravioli and hamburger patties in the freezer lacked dates, while shredded and mozzarella cheese in the refrigerator were improperly labeled or exposed. Staff interviews confirmed that opened items should be discarded within three days if not labeled with received, opened, and used-by dates, as per facility policy and FDA guidelines.
Two residents in an LTC facility did not receive necessary nail care, leading to hygiene issues and potential risks. One resident, not cognitively impaired, had nails protruding past fingertips with dirt and debris, while another, with severe cognitive impairment, had long, curling toenails and dirty fingernails. Despite care plans and policies, staff failed to follow through with interventions, highlighting a breakdown in communication and documentation.
The facility failed to ensure that call light pull strings in the bathrooms of three residents were free from entanglements and extended to their intended length, making them unreachable from the floor. This deficiency was observed in the bathrooms of a resident with moderate cognitive impairment and mobility issues, a resident with severe cognitive impairment and a history of falls, and a resident without cognitive impairments but with a high risk for falls. The call light pull strings were knotted multiple times, reducing their length and making them inaccessible, potentially placing residents at risk of being unable to call for assistance in case of a fall.
A facility failed to document a resident's tobacco use in the MDS assessment, despite the resident being identified as a safe smoker and observed smoking. This omission was confirmed by interviews with the MDS nurse, DON, and ADM, who stated that tobacco use should be reflected in the MDS and care plan to ensure accurate care planning. The resident's medical history included partial intestinal obstruction, pulmonary embolism, muscle weakness, and cardiac murmur.
A facility failed to conduct proper PASRR screening for a resident with schizophrenia, resulting in the resident not being referred for a necessary Level 2 evaluation. The MDS nurse, unaware of the resident's diagnosis, did not ensure accurate PASRR Level 1 information, leading to a lack of appropriate services. Interviews with staff revealed a lack of responsibility for ensuring correct screenings.
A facility failed to develop a baseline care plan within 48 hours for a resident with complex medical needs, including hemiplegia and diabetes, upon admission. Interviews with staff revealed that the admitting nurse was responsible for completing the care plan, but it was found blank and unsigned. This oversight could lead to unmet care needs and communication issues, contrary to the facility's policy requiring timely care plan development.
Two residents' care plans lacked critical information, with one missing details on a fentanyl patch and the other on smoking habits. Both residents were cognitively intact, yet their care plans did not reflect these important aspects, potentially affecting their care. Interviews with staff highlighted the importance of accurate MDS assessments for comprehensive care planning.
A resident admitted with a Foley catheter experienced discomfort and irritation, yet the facility failed to evaluate the necessity of the catheter or consult with a physician for its removal. Despite the resident's cognitive intactness and reported issues, staff did not adhere to the policy requiring assessment of catheter use, risking infection and urinary dependence.
A resident with a history of depression and cognitive impairment was given an incorrect dosage of Amitriptyline due to a transcription error at an LTC facility. The resident received 300 mg instead of the intended 10 mg, resulting in an acute drug overdose and hospitalization. The error was identified after the resident showed increased lethargy and family concerns about over-sedation.
A resident was prescribed Bupropion, an antidepressant, without a documented diagnosis or consent, contrary to facility policy. Interviews with the ADON and DON revealed that the expected process of obtaining consent and diagnosis upon admission was not followed, leading to the administration of the medication without proper documentation.
Failure to Remove Soiled Items and Maintain Infection Control
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for one resident who required assistance with activities of daily living. On the specified date, a soiled washcloth used by the resident was left on the bedside table, and a urinal bottle filled to the top was also left on the bedside table. The resident, who had diagnoses including congestive heart failure, type 2 diabetes, and hypertensive heart disease, reported using the call light early in the morning to request assistance from a CNA to remove the soiled items. The CNA responded initially but did not return to complete the tasks, leaving the soiled washcloth and full urinal unattended for several hours. Interviews with the CNA, DON, and ADM confirmed that it was the expectation for staff to remove soiled washcloths and empty urinals promptly to maintain infection control and prevent potential hazards. The CNA acknowledged forgetting to return to the resident after being called away to assist others. Facility policy required maintaining a safe and sanitary environment to prevent the transmission of infections, but these procedures were not followed in this instance, resulting in a failure to meet infection control standards.
Incomplete NPO Documentation in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who required nothing by mouth (NPO) status and tube feeding. Specifically, the resident's Medication Administration Record (MAR) did not have the required NPO documentation signed off by the assigned LVN during the overnight shift on two consecutive days. This omission was confirmed through record review, which showed that the NPO order, in place since early March, was not documented as completed on the specified dates and shift. The facility's policy requires all services and treatments provided to residents to be documented in the medical record, including the date, time, and signature of the staff member providing care. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that it was expected for the LVN to sign off on the MAR to ensure documentation was complete. Both acknowledged that the absence of a signature would indicate the task was not performed. Attempts to interview the responsible LVN and the resident's representative were unsuccessful. The resident involved had significant medical conditions, including type 2 diabetes, heart failure, dysphagia, and hypertension, and was unable to participate in interviews due to cognitive impairment.
Delayed Submission of PASARR Specialized Services Request
Penalty
Summary
The facility failed to submit a completed and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days from the Interdisciplinary Team (IDT) meeting for a resident with mild intellectual disabilities, diabetes, hypertension, chronic kidney disease stage 5, and a history of stroke. The resident was admitted with a care plan that included interventions such as physical therapy due to poor balance and an unrealistic sense of physical abilities. Despite recommendations from the PASARR evaluation for physical and occupational therapy, the required NFSS forms were submitted late and contained errors, resulting in repeated rejections and a final submission marked as late according to PASARR timelines. Interviews with facility staff, including the MDS-RN, DON, and ADM, confirmed that the MDS-RN was responsible for handling the PASARR process and that the failure to submit accurate and timely forms led to a delay in the resident receiving Medicaid Entitled Services, specifically physical and occupational therapy. Record review showed that the NFSS form was denied due to an incorrectly completed signature page, and the facility's policy did not specify a timeline for submission from the IDT meeting. This deficiency resulted in the resident not receiving the recommended specialized services in a timely manner.
Failure to Ensure Call Lights Were Accessible to Residents
Penalty
Summary
The facility failed to ensure that two residents received services with reasonable accommodations for their needs and preferences, specifically regarding the accessibility of their call lights. For one resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, observations revealed that her call light was on the floor and out of reach. The resident confirmed she could not access the call light and would have to yell for assistance if needed. Staff interviews acknowledged awareness of the importance of call light placement and that the call light was not within reach at the time of observation. Another resident, also severely cognitively impaired and dependent on staff, was observed with her call light placed on top of an oxygen concentrator approximately 2.5 feet from her bed, making it inaccessible. The resident stated she could not reach the call light and instead called out for help due to pain. A CNA responded to her calls and confirmed the call light should have been clipped to the bed sheet. Staff interviews indicated knowledge of the expectation for call lights to be within reach, and that the resident sometimes threw the call light away due to her cognitive impairment. Record reviews for both residents showed care plans that included interventions to ensure call lights were within reach, and facility policy required call lights to be easily accessible for residents in bed or confined to a chair. Despite these documented expectations and staff training, observations and interviews confirmed that the call lights were not within reach for these two residents at the time of the survey.
Inaccurate MDS Assessment for Insulin Administration
Penalty
Summary
The facility failed to conduct an accurate and comprehensive assessment for one resident, as required by federal regulations. Specifically, the Minimum Data Set (MDS) assessment for the resident incorrectly indicated that she was receiving insulin and injections, despite no physician's orders for such treatments and the resident's own statement that she had never received insulin. The resident's diagnoses included acute respiratory failure with hypoxia, diabetes, depression, and white matter disease, but her diabetes was managed without insulin, and she was reportedly doing well at the time of the assessment. Interviews with facility staff revealed that the LVN responsible for completing the MDS assessments was unsure whether the resident had received insulin or injections during the relevant period and acknowledged that if a resident was not receiving these treatments, the MDS should not reflect otherwise. The administrator and DON both stated their expectation that MDS assessments be completed accurately and confirmed that the RUG score, which is influenced by the MDS, determines facility reimbursement. Both also acknowledged that an inaccurate MDS could result in incorrect billing. A review of the facility's policy confirmed that comprehensive assessments must be completed within specified timeframes and must accurately reflect the resident's functional capacity and care needs. In this case, the inaccurate coding on the MDS assessment did not align with the resident's actual care and treatment, as documented in her records and confirmed by interviews, resulting in a deficiency related to the accuracy of resident assessments.
Failure to Administer Thyroid Medication Leads to Resident Neglect
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, specifically in the administration of her prescribed medication, Levothyroxine, which is used to treat hypothyroidism. The resident, who had a history of thyroid cancer and a thyroidectomy, did not receive her medication for an unknown period at the end of June and beginning of July 2024. This lapse in medication administration led to a significant elevation in her TSH levels, resulting in symptoms such as fatigue, dizziness, and depression. The resident's medical records indicated that she was cognitively intact and had been stable until the medication error occurred. Despite having a physician's order for daily Levothyroxine, the medication was not administered as prescribed. The resident experienced a noticeable change in her condition, including mental health deterioration, which she reported to the nursing staff. Lab results confirmed the elevated TSH levels, and the resident's NP noted the absence of medication administration, which was corroborated by the discovery of a nearly full blister pack of the medication. Interviews with facility staff revealed a lack of awareness regarding the missed medication doses. The ADON and DON acknowledged the oversight, with the ADON finding only a few pills missing from the blister pack and the previous month's pack unaccounted for. The resident expressed a loss of trust in the nursing staff due to this incident, and the NP confirmed that the resident's symptoms were consistent with not receiving her thyroid medication. The facility's policies on medication administration and abuse and neglect were not adhered to, leading to this deficiency.
Failure to Administer Thyroid Medication Leads to Resident's Health Decline
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident diagnosed with hypothyroidism. The resident did not receive her prescribed Levothyroxine medication for an unspecified period at the end of June and beginning of July 2024. This lapse in medication administration led to a significant elevation in her TSH levels, resulting in symptoms such as fatigue, dizziness, and depression. The resident's condition deteriorated to the point where she withdrew from therapy services and expressed a desire to give up. Interviews and record reviews revealed that the resident's thyroid medication was not administered as prescribed, with discrepancies noted in the medication administration records (MAR). The ADON discovered that only a few pills were missing from the blister pack, indicating that the medication had not been given consistently. The resident's NP confirmed that the resident had been stable until her depression worsened, correlating with the period she missed her thyroid medication. The NP noted that the resident's TSH levels were extremely high, confirming the lack of medication administration. The facility's failure to administer the medication as ordered was identified as an Immediate Jeopardy situation, highlighting the risk of not receiving the intended therapeutic benefits of medications. Interviews with staff indicated a lack of awareness and oversight regarding the medication administration process. The DON and ADON acknowledged the oversight, with the ADON noting that the nurse responsible for the lapse no longer worked at the facility. The facility's medication administration policy was not followed, leading to the resident's adverse health outcomes.
Deficiencies in Incontinent Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care for residents who are incontinent of bladder, leading to deficiencies in preventing urinary tract infections (UTIs). Resident #1, who had an indwelling catheter, was diagnosed with a UTI, but her Foley catheter was not changed until six days later, despite the presence of sediment and cloudy urine. Observations revealed that her catheter drainage bag was repeatedly found lying on the ground, which is against the facility's catheter care policy. The resident's responsible party, who is a nurse, expressed concerns about the unchanged catheter and the risk of bacteria remaining in the system. Resident #2, who was severely cognitively impaired and dependent on staff for toileting, did not receive proper incontinent care. Video footage showed that CNAs E and F removed her dirty brief and replaced it with a clean one without providing any cleaning or using wipes. The CNAs also failed to change gloves during the process, which could lead to contamination and infection. The facility's infection control policy emphasizes the importance of thorough cleaning to prevent infections. Resident #3, who had an indwelling catheter, did not receive proper infection control practices during peri and catheter care. CNA G did not follow enhanced barrier precautions (EBP) by failing to don a gown or mask and reused wipes multiple times during the cleaning process. The facility's policies require the use of PPE and single-use wipes to prevent infection. Interviews with staff indicated a lack of understanding and adherence to infection control protocols, which could increase the risk of UTIs and other infections.
Delayed Urine Analysis Collection Due to Supply Shortage
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who required a urine analysis (UA) due to increased confusion and altered mental status. The physician ordered a STAT UA on 07/19/24, but the specimen was not collected until 07/24/24 because the facility was out of UA specimen collection cups. This delay in collecting the urine sample resulted in a late diagnosis of a urinary tract infection (UTI) on 07/28/24, which required antibiotic treatment. Interviews with facility staff revealed a lack of communication and awareness regarding the shortage of specimen cups. The Assistant Director of Nursing (ADON) was not informed of the shortage until 07/22/24 and had to search for additional supplies. The Director of Nursing (DON) was unaware of the shortage and believed that specimen cups were available. The Physician Assistant (PA) and Nurse Practitioner (NP) were also not informed of the delay in collecting the specimen, which was against their expectations for timely testing. The facility's policy required staff to process test requisitions and arrange for tests, which was not adhered to in this case.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident, a male with cerebral palsy, spinal fusion, knee contractures, muscle weakness, and quadriplegia, was at risk of developing pressure ulcers. On June 30, 2024, several round red areas were identified on the resident's upper bilateral buttocks, with one area opening and causing pain and a burning sensation by July 3, 2024. Despite the identification of these skin issues, the facility did not obtain orders for wound care in a timely manner. The wound care nurse was not informed until July 2, 2024, and medical orders for treatment were not obtained until July 3, 2024. This delay in communication and action placed the resident at risk of improper wound management and potential complications. The resident expressed that he had not been seen by the wound care nurse recently and was unsure of the frequency of treatment, indicating a lack of adequate care. Interviews with staff revealed a breakdown in communication and adherence to the facility's skin management policy. The charge nurse was expected to document skin integrity issues and notify the wound care nurse and physician immediately, especially if an open area or pressure injury was present. However, the initial nurse who identified the issue did not notify the appropriate personnel, leaving the matter unresolved in shift reports. The Director of Nursing acknowledged that this practice did not meet expectations and could lead to worsening conditions if not addressed promptly.
Infection Control Deficiency During Peri Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during peri care for a resident. The CNAs did not adhere to proper infection control practices, which included failing to perform hand hygiene before donning gloves, reusing wipes during cleaning, and not changing gloves between dirty and clean tasks. These actions were observed during the care of a resident with severe cognitive impairment and a history of urinary tract infections, who required assistance with toileting due to incontinence. The CNAs' failure to follow the facility's Perineal Care Policy, which outlines the necessity of hand hygiene, single-use of wipes, and changing gloves between tasks, placed residents at risk for cross-contamination and the spread of infection. The Director of Nursing confirmed that the expected procedures were not followed, and one of the CNAs acknowledged the mistake, understanding that such practices could lead to infection.
Inadequate Respiratory Care for Residents Using BiPAP/CPAP
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents who required BiPAP and CPAP therapy, leading to potential health risks. Resident #1, a female with acute and chronic respiratory failure and obstructive sleep apnea, did not receive weekly filter cleanings for her BiPAP machine as per professional standards. Her medical records indicated multiple hospitalizations due to respiratory distress, with allegations that the facility did not ensure proper BiPAP mask placement. Observations revealed that her BiPAP machine's filter was dirty, and the settings did not match the physician's orders. Resident #2, diagnosed with COPD and obstructive sleep apnea, also did not receive the necessary weekly filter cleanings for her CPAP machine. During an observation, it was found that her CPAP machine lacked a filter entirely. Despite not experiencing exacerbations of her conditions, the absence of a filter posed a risk of infection and compromised respiratory care. The facility's policy required regular cleaning and maintenance of BiPAP/CPAP equipment, which was not adhered to. Interviews with staff and record reviews confirmed that the facility did not have replacement filters available, and staff were inaccurately documenting that the equipment was cleaned and maintained. The facility's failure to follow physician orders and maintain respiratory equipment placed residents at risk for infection and respiratory distress, as evidenced by Resident #1's repeated hospitalizations.
Improper Food Storage and Labeling in Dietary Services
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its dietary services, as observed during a survey. Specifically, the dietary staff did not properly reseal, label, and date food items in the walk-in refrigerator and freezer. During an initial tour of the kitchen, it was noted that the walk-in freezer contained bags of ravioli and hamburger patties without any documented dates. Similarly, the walk-in refrigerator had a bag of shredded cheese with a prepared date but no use-by date, and a bag of mozzarella cheese that was loosely opened and exposed to air. These lapses in food storage practices could potentially lead to food contamination and foodborne illness among residents. Interviews with the Dietary Manager and other staff members revealed that there was an expectation for opened food items to be discarded within three days if not properly labeled with received, opened, and used-by dates. The Dietary Manager acknowledged that improperly labeled food could become old, moldy, or develop an odor, posing a risk to residents if consumed. The facility's policy, as well as the FDA's 2022 Food Code, requires that all time/temperature control for safety foods be stored in a manner that prevents cross-contamination and includes clear date marking for items held for more than 24 hours. The failure to comply with these standards was confirmed by the ADM, who stated that improperly labeled food could result in serving spoiled food to residents.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary nail care for two residents, leading to issues with personal hygiene and potential risks to their well-being. Resident #7, who was not cognitively impaired and required substantial assistance for personal hygiene, was observed with nails protruding past the fingertips, some nails gagged, and dirt or debris under the nails. Despite having care plans in place to maintain personal hygiene and prevent skin integrity issues, the nursing staff did not follow through with the interventions to check, trim, and clean the resident's nails as necessary. Resident #40, who had severe cognitive impairment and required maximum assistance with personal hygiene, was also neglected in terms of nail care. Her fingernails were long and dirty, and her toenails were excessively long, curling, and splitting. Despite multiple records indicating the need for toenail care, the facility staff failed to address these needs. Observations revealed that the resident had accidentally scratched herself due to the long nails, and she expressed a desire for better care. Interviews with staff, including CNAs and LVNs, highlighted a breakdown in communication and follow-through regarding the residents' nail care needs. The facility's policy required daily cleaning and regular trimming of nails, but this was not adhered to, as evidenced by the observations and interviews. The ADON and ADM acknowledged the failure in communication and documentation, which resulted in the residents not receiving the necessary nail care, as outlined in their care plans.
Inaccessible Call Light Pull Strings in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the call light pull strings in the bathrooms of three residents were free from entanglements and extended to their intended length, making them reachable from the floor. This deficiency was observed in the bathrooms of Resident #41, Resident #10, and Resident #51. The call light pull strings were found to be knotted multiple times, which reduced their length and made them inaccessible from the floor, potentially placing residents at risk of being unable to call for assistance in case of a fall. Resident #41, a female with moderate cognitive impairment and mobility issues, was observed to have a call light pull string knotted four times, reducing its length to 25 inches from the floor. Despite multiple observations over consecutive days, the string remained knotted and inaccessible. Resident #10, a male with severe cognitive impairment and a history of falls, had a call light pull string wrapped and knotted around a support bar, rendering it inoperable and only 23 inches from the floor. Similarly, Resident #51, a female without cognitive impairments but with a high risk for falls, had a call light pull string knotted ten times, reducing its length to 27.5 inches from the floor. Interviews with staff and residents revealed a lack of awareness and understanding of the importance of the call light system's accessibility. Staff were trained to ensure the call light strings were in their intended position, but the failure to recognize and correct the strings' placement was evident. The facility's policy required staff to explain and demonstrate the call light system to residents, but the deficiency indicated a lapse in adherence to this policy, leading to the inaccessibility of the call light pull strings in the residents' bathrooms.
Failure to Document Tobacco Use in Resident's MDS Assessment
Penalty
Summary
The facility failed to complete an accurate assessment for a resident, specifically regarding tobacco use, which was not reflected in the resident's Admission MDS assessment. The resident, a male with a history of partial intestinal obstruction, pulmonary embolism, muscle weakness, and cardiac murmur, was admitted to the facility and assessed with a BIMS score indicating cognitive intactness. Despite being identified as a safe smoker in a smoking risk assessment and being observed smoking, the resident's tobacco use was not documented in the MDS or care plan. Interviews with the MDS nurse, DON, and ADM confirmed that tobacco use should have been documented in both the MDS and care plan to ensure accurate care planning and prevent potential negative outcomes. The facility's policy on Care Area Assessments emphasizes the importance of accurate MDS assessments to develop individualized care plans. The failure to document the resident's tobacco use in the MDS and care plan placed the resident at risk of not receiving appropriate care and services.
Failure to Conduct Proper PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a resident diagnosed with mental illness was properly screened and evaluated prior to admission, as required by the PASRR process. Specifically, the facility did not refer a resident with a diagnosis of schizophrenia to the appropriate state-designated mental health authority for evaluation. This oversight was identified during a review of the resident's records, which showed conflicting information regarding the presence of mental illness. The PASRR Level 1 screening form initially indicated evidence of mental illness, but a subsequent form did not, leading to a failure in obtaining the necessary PASRR Level 2 evaluation. Interviews with facility staff, including the MDS nurse, DON, and Administrator, revealed a lack of awareness and responsibility for ensuring accurate PASRR Level 1 screenings. The MDS nurse, who was new to the facility, was unaware of the resident's schizophrenia diagnosis and the implications for PASRR screening. Both the DON and Administrator acknowledged that an inaccurate PASRR Level 1 screening would prevent the resident from receiving appropriate services and care. The facility's PASRR Clinical Policy outlines the requirement for a PASRR Level 2 evaluation when mental illness is indicated, but this was not followed in this case.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, a female with a history of hemiplegia and hemiparesis following a cerebral infarction, hypothyroidism, weakness, type 2 diabetes mellitus, and heart failure, was admitted from a rehab hospital. She required extensive assistance with mobility and daily activities, was alert and oriented, and had a Foley catheter upon admission. Despite these needs, the baseline care plan for the resident was found to be blank and unsigned, indicating that it was not completed as per the facility's policy. Interviews with facility staff, including a registered nurse, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that the baseline care plan should have been completed at the time of admission by the admitting nurse. The ADON and DON both acknowledged that the lack of a completed baseline care plan could lead to a lack of communication and unmet care needs for the resident. The facility's policy, dated December 2016, mandates that a baseline care plan be developed within 48 hours of admission to ensure residents' immediate care needs are met, but this was not adhered to in this case.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which resulted in deficiencies in addressing their specific needs. Resident #35, a cognitively intact male with a history of cerebral infarction, type 1 diabetes mellitus with ketoacidosis, and chronic pain, had a care plan dated 02/20/2024 that did not include the management of his fentanyl patch, which was prescribed for pain management. Despite having a physician's order for the fentanyl patch since 05/17/23, this critical aspect of his care was omitted from the care plan. Similarly, Resident #44, also cognitively intact, was admitted with diagnoses including partial intestinal obstruction and pulmonary embolism. His care plan dated 01/26/24 failed to address his tobacco use, despite observations and interviews confirming that he smoked regularly at the facility. The facility's smoking list included him as a smoker, yet this information was not reflected in his care plan or MDS assessment, potentially leading to safety risks. Interviews with the MDS nurse, DON, and ADM revealed a consensus that the care plans should accurately reflect all aspects of a resident's care, including opioid use and smoking habits. The failure to include these elements in the care plans was attributed to inaccuracies in the MDS assessments, which are crucial for developing comprehensive care plans. The facility's policy mandates that care plans include measurable objectives and timetables, and be updated with any significant changes in a resident's condition, which was not adhered to in these cases.
Failure to Evaluate and Justify Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident who was incontinent of bladder, specifically in preventing urinary tract infections and evaluating the need for an indwelling catheter. The resident, a cognitively intact female with a history of hemiplegia, hypothyroidism, diabetes, and heart failure, was admitted with a Foley catheter from a rehab hospital. Despite the resident's report of irritation and discomfort from the catheter, there was no documented evaluation or justification for its continued use upon admission. Interviews with facility staff, including an RN, ADON, and DON, revealed a lack of adherence to the facility's policy requiring evaluation of the necessity of a Foley catheter for newly admitted residents. The staff acknowledged the risks associated with prolonged catheter use, such as infection and urinary dependence, but failed to initiate a voiding trial or consult with a physician or urologist to assess the resident's condition. The facility's policy mandates that the attending physician and staff evaluate the potential for catheter removal, which was not followed in this case.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide medically-related social services to help a resident achieve the highest possible quality of life. Specifically, the facility did not provide appropriate behavioral health services and interventions to prevent or improve the depressive behaviors of a resident. The resident, a male with a history of heart attack, metabolic encephalopathy, anemia, dementia, and type 2 diabetes, was admitted to the facility and was cognitively impaired with a BIMS score of 8. Despite being on an antidepressant medication with a goal to remain free from signs and symptoms of depression, the facility's care plan only included administering medications as ordered and arranging psychiatric consults as needed. A significant error occurred when a family member requested the continuation of the resident's home medication, Amitriptyline. The facility received an order for 300 mg of Amitriptyline to be administered twice daily, which was a transcription error. The resident received a dose of 300 mg, leading to an acute drug overdose and subsequent hospitalization. The nurse practitioner (NP) identified the error after being notified of the resident's increased lethargy and family concerns about over-sedation. The NP confirmed that the order should have been for 10 mg at bedtime, not 300 mg twice daily, resulting in the resident being sent to the hospital for evaluation of adverse effects related to the medication error.
Failure to Document Justification for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, who had not previously used psychotropic drugs, was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, Resident #230 was prescribed Bupropion, an antidepressant, without a documented diagnosis to justify its use. The resident's care plan did not include any antidepressant medications, and there was no medication consent on file for Bupropion. This oversight could lead to adverse consequences for the resident, such as impairment or decline in mental or physical condition. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's expectation was to obtain consent and a diagnosis for any psychotropic medication upon admission. However, this process was not followed for Resident #230. The facility's policy on medication utilization and prescribing requires that medications be prescribed in response to an identified problem or condition, considering the resident's age, condition, risks, health status, and existing medications. The failure to adhere to these procedures resulted in the administration of Bupropion without proper documentation or consent.
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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 Hewitt
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Waco | 1.2 mi | ★★★★★ | 7 | 0 |
| St. Anthony's Care Center | 1.2 mi | ★★★★★ | 4 | 0 |
| Wesley Woods Health & Rehabilitation | 1.9 mi | ★★★★★ | 7 | 0 |
| Woodway Rehabilitation And Healthcare Center | 3.1 mi | ★★★★★ | 2 | 0 |
| The Chateau Waco | 3.4 mi | ★★★★★ | 7 | 2 |
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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.