Two days later, the same resident set their bed on fire.
Licensed Practical Nurse #2 told federal inspectors she knew the resident was "unusually angry" on December 27, 2025, but decided against notifying the nursing supervisor or any medical provider. Instead, she wrote notes in a psychiatric book, even though she knew the psychiatric nurse wouldn't visit the facility for three more days.
The resident's condition deteriorated rapidly. By December 29, staff found the patient "extremely agitated, throwing things, yelling at staff" and making threatening statements toward the building. Emergency responders transported the resident to the hospital after they set their bed on fire.
Hospital records show the resident arrived at the emergency department complaining of feeling unwell and displaying severe agitation. The crisis team was consulted specifically because of "the report that Resident #1 had set his/her bed on fire." Doctors diagnosed a urinary tract infection and started antibiotics. After crisis team evaluation, the resident was cleared to return to the facility on December 31.
LPN #2 told inspectors during a January 2 interview that looking back, "she should have notified the nursing supervisor on 12/27/25 so the on-call provider could have been notified." She explained the resident "was unable to be redirected and had no available as needed medication to calm him/her down."
Licensed Practical Nurse #1, who also cared for the resident, said that while the patient had a history of refusing care, "on 12/29/25, Resident #1 was angrier and agitated than she had ever observed before."
The facility's psychiatric nurse practitioner was direct in her assessment. She told inspectors "a provider should have been notified" of the resident's December 27 behaviors, stating flatly that what LPN #2 documented "was not the resident's baseline."
The nurse practitioner identified crucial missed opportunities. The resident had a history of urinary tract infections and had recently undergone a reduction of Seroquel, an anti-psychotic medication, in November. Had a provider been notified on December 27, "a urine and blood work could have been ordered as well as an as needed medication."
Director of Nursing confirmed the failures during her January 2 interview. She told inspectors both "the nursing supervisor and a provider should have been notified" of the resident's December 27 behaviors. She called LPN #2's decision to only document in the psychiatric book inappropriate, stating "the medical APRN or psychiatric APRN should have been contacted for a telehealth appointment."
The facility's own policy, dating to July 2018, requires immediate notification when there's "a significant change in the condition of a resident's physical, mental or emotional status." The policy outlines a clear chain of contact: attending physician first, then covering physician if unavailable, then medical director. It mandates that "a RN assessment will be conducted" and documentation that "the physician and family or responsible party have been notified."
None of this happened.
The inspection found the charge nurse's judgment particularly troubling. She witnessed behaviors severe enough that the resident "was unable to be redirected" and had "no available as needed medication to calm him/her down," yet she made no calls. Her explanation that she attributed the violence to the resident "not liking change" directly contradicted the observations of colleagues who said the agitation was unlike anything they had seen before.
The two-day gap between the initial violent episode and the bed fire represents a critical window when proper medical intervention might have prevented the escalation. The resident's urinary tract infection, ultimately diagnosed at the hospital, was a treatable condition that could explain the behavioral changes.
Federal inspectors classified this as a violation of residents' rights to receive proper medical care when their condition changes. The resident returned to the facility after hospital clearance, but the case illustrates how delayed medical response can lead to dangerous situations for vulnerable nursing home patients.
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.