Hewitt Health & Rehab: Nurse Ignored Behavior Warning - CT
Two days later, the resident set his bed on fire.
The January 2 inspection, triggered by a complaint, documented what happened in the days before and after that fire. Inspectors interviewed nursing staff, an advanced practice registered nurse, and the Director of Nursing. What emerged was a straightforward failure: a nurse saw something wrong, decided it wasn't her problem to escalate, and a resident ended up in an emergency room.
On December 27, the resident, identified in the report only as Resident #1, was unusually angry. Licensed Practical Nurse #2, the charge nurse that shift, acknowledged to inspectors that the resident was unable to be redirected and had no available as-needed medication to calm him down. She didn't call the nursing supervisor. She didn't call the on-call provider. She wrote the behaviors in the psychiatric APRN's book, even though she knew that APRN wasn't scheduled to visit the facility for another three days.
Her explanation: she attributed the outbursts to the resident not liking change.
By December 29, LPN #1 told inspectors the resident was "angrier and agitated than she had ever observed before." That same day, the resident set his bed on fire. He was sent to the emergency department, where the crisis team was consulted and he was diagnosed with a urinary tract infection and started on antibiotics. The hospital cleared him to return to the facility. He came back on December 31.
The APRN told inspectors that what LPN #2 documented on December 27 was not the resident's baseline, and that a provider should have been called that day. The resident had a documented history of urinary tract infections. He had also recently undergone a gradual dose reduction of Seroquel, an antipsychotic medication, in November. Had a provider been reached on December 27, the APRN said, urine and bloodwork could have been ordered. An as-needed medication could have been prescribed.
None of that happened.
The Director of Nursing was direct with inspectors: it was not appropriate for LPN #2 to write the behaviors only in the psychiatric APRN book. The medical APRN or psychiatric APRN should have been contacted for a telehealth appointment. The nursing supervisor and a provider should have been notified the same day the behaviors appeared.
LPN #2, looking back, agreed. She told inspectors she should have notified the nursing supervisor on December 27 so the on-call provider could have been reached. She said she understood that now.
The facility's own policy, in place since July 2018, required staff to notify the attending physician when a resident showed a significant change in physical, mental, or emotional status. If the attending wasn't available, the covering physician. If neither was reachable, the medical director. The policy also required a registered nurse assessment and documentation that the physician and family had been notified.
None of that was followed on December 27.
What was followed, instead, was a charge nurse's judgment that a resident who couldn't be redirected, had no medication available to calm him, and was behaving in a way his own treatment team later said wasn't his baseline, was probably just annoyed about something.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The resident returned to the facility on New Year's Eve, two days before inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hewitt Health & Rehabilitation Center, Inc from 2026-01-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
HEWITT HEALTH & REHABILITATION CENTER, INC in SHELTON, CT was cited for violations during a health inspection on January 2, 2026.
Two days later, the resident set his bed on fire.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.