Hewitt Health & Rehabilitation Center, Inc

Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for resident rights, the facility failed to honor the residents right to refuse care when a resident requested staff to stop providing incontinent care.

Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to notify the State Agency timely after they were aware of an allegation of abuse.

Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided in accordance with the plan of care.

Inspectors wroteBased on facility documentation review and staff interviews for one of three residents (Resident #1) reviewed for Administration review, the facility failed to ensure a staff member spoke effectively to communicate with a resident when providing care.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for a change in condition, the facility failed to ensure the provider was notified at the time a change in behavioral symptoms was noted.

Inspectors wroteBased on interviews and review of the Payroll Based Journal (PBJ) submissions, the facility failed to provide the appropriate number of weekend staff for Quarter 1 and Quarter 2 of Fiscal Year (FY) 2024 (October 1, 2023 through March 31, 2024).

Inspectors wroteBased on review of the clinical record, facility policy and interviews for 4 of 32 residents (Resident #31, Resident #94, Resident #214 and Resident #315) reviewed for Advance Directives, the facility failed to follow facility policy for completion of resident's choices for advance directives.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 3 of 4 residents (Resident #1, Resident #53, Resident #78 and Resident #85) reviewed for nutrition, the facility failed to notify the resident representative (Resident #1, Resident #53 and Resident #78) and failed to notify the physician (Resident #85) of a weight loss.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 residents (Resident #6, Resident #98, and Resident #110) reviewed for smoking, the facility failed to ensure timely completion of smoking assessments, to secure smoking materials per the resident plan of care (Resident #6), and failed to provide supervision to a resident smoking (Resident #6) per the smoking assessment.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #264) reviewed for abuse, the facility failed to ensure a medication was administered as indicated by the physician's order which resulted in Resident #264 receiving a psychotropic medication.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #18) reviewed for abuse, the facility failed to report an injury of unknown origin to the State Agency (SA) timely.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #44) reviewed for pressure injury, and 1 of 3 residents (Resident #264) reviewed for falls, the facility failed to ensure completion of an Registered Nurse (RN) assessment after a resident fell (Resident #44) and the identification of a new pressure ulcer (Resident #264).

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews, for the only sampled resident (Resident #21) reviewed for activities of daily living, the facility failed to maintain clean and trimmed fingernails.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #85) reviewed for edema, the facility failed to weigh the resident per physician orders.

Inspectors wroteBased on observations, interviews, record and policy reviews for 1 of 3 residents (Resident #106) sampled for pressure injuries, the facility failed to provide treatment for a wound per physician's order and failed to transcribe wound orders accurately.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #25) reviewed for medication administration, the facility failed to administer medications per the physician's order resulting in a medication error rate greater than 5%.

Inspectors wroteBased on observation(s), review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #18) reviewed for skin condition (non-pressure), and for 1 of 4 residents (Resident #106) reviewed for pressure injury, the facility failed to ensure proper personal protective equipment (PPE) were donned ( placed on ) during wound care for a resident on enhanced barrier precautions (EBP) and the facility failed to ensure proper hand hygiene was performed during wound care.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #44) reviewed for pressure injury, and for 1 of 4 residents (Resident #78) reviewed for nutrition, the facility failed to complete a significant change in status (SCSA) Minimum Data Set (MDS) assessment for a resident with a decline in 2 or more areas.

Inspectors wroteBased on review of the clinical record, facility policy and interview for one of one resident (Resident #80) reviewed for timeliness of care planning, the facility failed to conduct a quarterly care conference.

Inspectors wroteBased on observation, interviews, facility documentation, and review of facility policy for 1 of 2 medication storage rooms, the facility failed to maintain proper refrigerator temperatures for medication storage.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for an accident, the facility failed to ensure Resident #2 had Geri-leg sleeves applied per the physician's order to prevent a left leg laceration that required sutures and steri-strips.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who exhibited behavioral symptoms, the facility failed to ensure a change in the anti-anxiety medication, Ativan, order was sent to the pharmacy and a follow through with the pharmacy when the Ativan was not available to prevent missed doses which resulted in Resident #1 having increased anxiety and agitation.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of abuse and neglect, the facility failed to ensure resident safety by removing a staff member from resident care after an allegation of abuse was reported in accordance with the facility's policy.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of three (3) residents reviewed for falls, (Resident #1 and Resident #2), the facility failed to ensure a safety device was utilized for transfers and ambulation in accordance with facility policy resulting in falls with injuries.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #3) who were reviewed for comprehensive care plans, the facility failed to develop a care plan to address Resident #3's scissoring movements of his/her legs.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who were discharged home, the facility failed to provide documentation a medication reconciliation and review was conducted with the resident and/or family member to ensure a safe discharge.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of six (6) residents, (Resident #2), who was reviewed for abuse, the facility failed to ensure incontinent care was provided to a resident who required total care with incontinent care.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of six (6) residents who were reviewed for abuse, (Resident #1), the facility failed suspend an employee pending the outcome of an abuse investigation.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of six (6) residents reviewed for allegations of abuse, (Resident #1), the facility failed to report an allegation of neglect to the state agency within required time frames.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents reviewed for abuse, (Resident #1),the facility failed to ensure a complete and thorough investigation was completed and finalized in a timely manner following an allegation of neglect.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of six (6) residents reviewed for allegations of neglect, (Resident #1), the facility failed to ensure that a resident who is dependent on staff for care was provided with incontinent in a timely manner.

Inspectors wroteBased on facility documentation, facility policy and interviews, the facility failed to ensure sufficient staffing levels to meet the needs of the residents.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for two (2) of six (6) residents, (Resident #2 and Resident #3) who were reviewed for abuse, the facility failed to ensure a complete and accurate clinical record.

Inspectors wroteBased on observation, staff interview and review of facility policy for 4 of 9 sampled residents (Resident #22, Resident #31, Resident #49 and Resident #56) observed for dining, the facility failed to provide a dignified dining experience as evident by utilizing hospital gowns (Resident #22, Resident #31 and Resident #49) and a bath towel (Resident #56) as clothing protectors during a meal.

Inspectors wroteBased on tour with the Maintenance Director, observations, and interview, the facility failed to ensure a clean, comfortable, homelike environment related to marred furniture, soiled privacy curtains, walls in disrepair, main hall hand rails marred and overhead hall lights with debris and/or black specs. Observation of the environment on 1/9/23 at 10:53 AM and on 1/17/23 at 11:50 AM with the facility Maintenance Supervisor identified the following on Unit 1 A: 1. room [ROOM NUMBER]-1: the facility provided nightstand handle of the top drawer was dangling and the laminate trim was missing from around the table top, exposing the press board beneath. Additionally, the radiator in the room was marred and rusty. 2. room [ROOM NUMBER]: The bathroom and closet doors were marred. 3. room [ROOM NUMBER]: The bathroom door was marred, the wall adjacent to the left of the bathroom was marred. 4. [...]

Inspectors wroteBased on observations, staff interviews and clinical record review for 1 of 1 sampled residents (Resident #20) reviewed for enteral tube feeding, the facility failed to ensure water bolus physician orders were completed.

Inspectors wroteBased on review of facility staff training documentation and interviews, the facility failed to ensure that staff completed annual training and competencies related to providing Intravenous Therapy.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 40) reviewed for accidents, the facility failed to ensure a resident's medication was stored in a safe manner and inaccessible to a resident not assessed for self-medication administration and 1 of 3 medication rooms, the facility failed to monitor and document medication refrigerator storage temperatures.

Inspectors wroteBased on a review of the facility Infection Control Program for Immunizations, review of facility documentation and interview for 3 out of 5 residents ( Residents # 16 and #58), the facility failed to provide evidence that a consent and education for influenza and pneumovax vaccines were provided to the residents prior to the administration of the vaccine and failed to provide evidence that for ( Resident # 83 ),the pneumovax vaccine was offered to the resident.

Inspectors wroteBased on review of the clinical record, observation, facility policy and interviews for 1 resident (Resident # 30) reviewed for accommodation of needs, the facility failed to ensure a call light was accessible for the resident.

Inspectors wroteBased on review of the clinical record, observation, facility policy, and interviews for 1 resident (Resident # 30) reviewed for choices, the facility failed to ensure a resident's preference for returning to bed was honored.

Inspectors wroteBased on clinical record review, facility policy review, and interviews for 1 of 3 residents (Resident #94) reviewed for advanced directives, the facility failed to ensure a physician's order was obtained per facility policy.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 68) reviewed for hospitalizations, the facility failed to notify the Advanced Practice Registered Nurse (APRN) and the physician of a medication error.

Inspectors wroteBased on clinical record reviews, facility documentation review, facility policy review, and interviews for 2 of 3 residents reviewed for abuse and neglect for (Resident #60), the facility failed to prevent physical abuse and for (Resident #65), the facility failed to ensure the resident was free from neglect as the resident was not provided incontinent care and repositioning in accordance with facility policy.

Inspectors wroteBased on clinical record review, review of facility documentation and interviews for 1 resident (Resident # 55) reviewed for electronic movement alarms, the facility failed to notify the state agency within 5 days of an injury of unknown origin.

Inspectors wroteBased on clinical record reviews, facility policy review, and interviews for 1 sampled resident (Resident #60) reviewed for hospitalization, the facility failed to provide evidence of transfer documentation to an acute care facility for a change in status and for 1 residents (Resident # 96) reviewed for discharge, the facility failed to ensure a physician's order for the resident's discharge was obtained in accordance to facility policy.

Inspectors wroteBased on clinical record reviews, facility policy, and interviews for 1 resident (Resident #55) reviewed for care planning, the facility failed to develop and implement a comprehensive person-centered care plan with interventions that included a reduction plan for the use of a position change alarm and failed to ensure floor mats were properly placed at the bedside for a resident at risk for falls.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 68) reviewed for hospitalizations, the facility failed to ensure medications were administered according to standards of care for a resident prescribed antibiotic therapy upon re-admission and a medication error report was completed in accordance to facility practice to meet professional standards.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews 1 of 1 sampled residents (Resident #6) reviewed for a non-pressure wound, the facility failed to measure the wound when it developed and for 1 resident (Resident #65) reviewed for pressure ulcer prevention, the facility failed to ensure the residents low air loss (LAL) mattress was assessed for function every shift and failed to ensure there was an physician's order present to check the function of the LAL mattress and for 1 resident (Resident # 68) reviewed for hospitalizations, the facility failed to follow hospital discharge recommendations for a resident requiring continued use for antibiotic therapy and enteral tube feedings and use of respiratory equipment.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents reviewed for weight loss for ( Resident # 24), the facility failed to monitor the residents weights and for (Resident # 68) reviewed for nutrition, the facility failed to address a significant weight discrepancy in a timely manner and according to facility policy.

Inspectors wroteBased on review of the clinical record, observations, facility policy and interviews for 1 resident (Resident # 68) reviewed for respiratory equipment, the facility failed to ensure respiratory equipment was stored according to infection control standards and failed to ensure that staff followed facility practice for glucometer cleaning and 1 of 1 sampled residents (Resident #20) reviewed for enteral tube feeding, the facility failed to ensure cleanliness of the tube feeding pump.

Inspectors wroteBased on observations and interview, the facility failed to ensure 3 sections of handrails were attached securely to the wall. Observation on 1/9/23 at 10:53 AM and on 1/17/23 at 11:50 AM with the facility Maintenance Supervisor identified the following: 3 sections of handrails were not securely attached to the wall on Unit 1 A located between room [ROOM NUMBER] and room [ROOM NUMBER], between the nursing station and the utility room, and by elevator A which was next to the Purell hand sanitizer station. Interview with the Maintenance Supervisor on 1/17/23 during the 11:50 AM tour indicated although environmental rounds are completed monthly he did not identify loose handrails.

Inspectors wroteBased on staff/resident interviews the facility failed to ensure mail was delivered to residents on Saturdays after delivery from the postal service.

Inspectors wroteBased on interviews the facility failed to ensure snacks were passed out after dinner/before bed on Unit 1A.

Inspectors wroteBased on clinical record review, facility documentation, facility policy, and interviews for 1 of 6 sampled residents (Resident #31) reviewed for, pre-admission screening and resident review (PASRR), the facility failed to ensure a referral was made to the state designated authority when a new psychiatric diagnoses were identified.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for 3 sampled residents (Residents #2, #14 & #33) reviewed for medication administration and activities of daily living, the facility failed to ensure sufficient staff to provide timely care and services.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #33) who required assistance with activities of daily living, the facility failed to ensure the provision of care in a timely manner.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #37) reviewed for choices, the facility failed to ensure that a resident who was self-administering a medication was assessed for safety.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 sampled residents (Resident #29 & #502) reviewed for falls, the facility failed to implement care plan interventions and provide the necessary supervision for residents with a history of falls.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #62) reviewed for nutrition, the facility failed to ensure weights were obtained according to dietitian recommendations.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #65) reviewed for dignity, the facility failed to appropriate provide care and treatment for a resident with dementia.

Inspectors wroteBased on observation, clinical record review and facility staff interviews for 1 of 4 sampled residents (Resident #14) observed for medication administration, the facility failed to administer medications as directed by the physician, resulting in a medication error rate over 5%.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #37) reviewed for choices, the facility failed to ensure a medication was stored in a secure location.

Inspectors wroteBased on observation, facility documentation, facility policy, and interviews, the facility failed to consistently sign Controlled Substance Change of Shift Audit sheets to signify audits were performed.