Hewitt Health & Rehabilitation Center, Inc

In the surveyor’s words

From the most serious findings on record at Hewitt Health & Rehabilitation Center, Inc, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 1, 2024

  Based 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. The findings include: 1. Resident #2 had diagnoses that included dementia and osteoporosis. A physician's order dated 3/7/24 directed an assist of one for transfers with rolling walker. The quarterly MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition and required extensive assistance of one staff for transfers. […]

• No harm, potential for more than minimal, widespreadF725May 19, 2025

  Based 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). The findings include: PBJ submissions for Quarter 1 and Quarter 2 of FY 2024 (October 1, 2023 through March 31, 2024). indicated the facility had triggered for excessively low weekend staffing. An interview with the Scheduler on 5/16/25 at 9:36 AM identified she was not responsible for submitting staffing reports to PBJ and was not aware that the facility had triggered for low weekend staffing for Quarters 1 and 2 of FY 2024. […]

• No harm, potential for more than minimal, patternF578May 19, 2025

  Based 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. The findings include: 1. Resident #31's diagnoses included paranoid schizophrenia, malignant neoplasm of the kidney, and lymphedema. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 was cognitively intact and was independent with eating, bed mobility and transfers. The Resident Care Plan (RCP) dated [DATE] identified Resident #31 required staff assistance with his/her activities of daily living. […]

• No harm, potential for more than minimal, patternF580May 19, 2025

  Based 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. The findings include: 1. Resident #1's diagnoses included dementia, depression, and anemia. Review of the face sheet in the clinical record identified Resident #1 was not responsible for him/herself and a family member was the resident representative. […]

• No harm, potential for more than minimal, patternF689May 19, 2025

  Based 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. The findings include: 1. Resident #6's diagnoses included end stage heart failure, asthma, and acquired absence of the left leg. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was cognitively intact and was independent with toileting, bed mobility, and transfers. […]