Health inspection·January 11, 2024

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of RES #2's medical records reflected the immunization of the influenza immunization with [No Date Given] and RES #2's Consent Status was [Consent Refused.] Record review of PCC did not document a Pneumococcal Vaccination, a date given, or consent status. Record review of RES #2's Order Summary Report indicated, on 7/26/2023, an order for pneumococcal vaccine and annual influenza vaccine. Record review of RES #4's AR, dated 1/11/2024, reflected RES #4 was a [AGE] year-old male who was admitted the facility on 12/9/2023. He was diagnosed with Metabolic Encephalopathy (which was a chemical imbalance in the blood) and Muscle Weakness. Record review of RES #4's admission MDS, dated [DATE], indicated Section C., Cognitive Patterns, that RES #4 had a BIMS Score of 10. A BIMS Score of 10 indicated RES # had moderate cognitive impairment. RES #4's admission MDS, indicated, Section O., Special Treatments, Procedures, and Programs, that RES #4's influenza vaccination, Sub-Section O0250., was [not received;] RES #4 did not receive the influenza vaccination due to having had [received the influenza vaccination outside of the facility.] RES #4's admission MDS, indicated, Section O., Special Treatments, Procedures, and Programs, that RES #4's Pneumococcal vaccination, Sub-Section O0300., was [not up to date;] RES #4 did not receive the Pneumococcal Vaccination due to [having received it outside of the facility.] Record review of RES #4's medical records reflected no documentation of the [influenza Vaccination]; did not document a [Date Given] and did not document a [Consent Status.] Record review of RES #4's medical records, listed under the Immunizations Tab in PCC did not indicate [Pneumococcal Vaccination]; did not document a [Date Given] and did not document a [Consent Status.] Record review of RES #4's Order Summary Report indicated, on 7/26/2023, an order for pneumococcal vaccine and annual influenza vaccine. Interview and record review on 1/11/2024 at 2:20 PM with the ADON of RES #2's medical records resulted in a facility failure to provide documentation that pertained to (1) RES #2, or their RP, having had received education regarding the benefits and potential side effects of the influenza immunization; (2) RES #2, or their RP, having had documented the date of RES #2's influenza immunization between October 1,2023 through the date of the date of the assessment; or (3) RES #2, having been found ineligible for the influenza immunization due to medical contradiction. The only documentation found in PCC was found in a drop-down box in the influenza section, under Immunizations, which indicated RES #2 refused the influenza vaccination on 7/16/2023, prior to RES #2's admission to the facility on 7/26/2023. A search of RES #2's medical records in PCC resulted in a facility failure to provide documentation that pertained to (1) RES #2, or their RP, having had received education regarding the benefits and potential side effects of the pneumococcal immunization; (2) RES #2, or their RP, having had documented the date of RES #2's previous pneumococcal immunization; or (3) RES #2, having been found ineligible for the pneumococcal immunization due to refusal or medical contradiction. A search of RES #4's medical records resulted in a facility failure to provide documentation that pertained to (1) RES #4, or their RP, having had received education regarding the benefits and potential side effects of the influenza immunization; (2) RES #4, or their RP, having had documented the date of RES #4's influenza immunization between October 1,2023 through the date of the date of the assessment; or (3) RES #4, having been found ineligible for the influenza immunization due to refusal or medical contradiction. A search of RES #4's medical records in PCC resulted in a facility failure to provide documentation that pertained to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676213 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hewitt Nursing and Rehabilitation 8836 Mars Dr Hewitt, TX 76643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (1) RES #4, or their RP, having had received education regarding the benefits and potential side effects of the pneumococcal immunization; (2) RES #4, or their RP, having had documented the date of RES #4's previous pneumococcal immunization; or (3) RES #4, having been found ineligible for the pneumococcal immunization due to refusal or medical contradiction. Interview on 1/11/2024 at 2:30 PM with RES #2 revealed an inability to recall if the facility offered the influenza immunization or the pneumococcal immunization since his arrival to the facility. RES #2 was unable to recall if he refused the influenza immunization on 11/16/2023. Interview on 1/11/2024 at 2:40 PM with RES #4 revealed an inability to recall if the facility offered the influenza immunization or the pneumococcal immunization since his arrival to the facility. Interview on 1/11/2024 at 2:456 PM with LVN revealed that everyone at the facility was offered the influenza and pneumococcal immunizations per facility policy. The immunizations were offered to all residents, regardless of whether they were short-term rehab patients or long-term residents. The LVN stated that information pertaining to the influenza and pneumococcal immunization, such as benefit and risk, was provided to each resident, or their RP, as to make an informed decision. The LVN stated that the facility was supposed to keep consents and refusals for influenza and pneumococcal immunization on file and that the influenza and pneumococcal immunization status was found under the immunization section of PCC. Interview on 1/11/2024 at 2:55 PM with the DON revealed the facility failure to document education, receipt, and medical contradiction for influenza and pneumococcal immunizations was due to staffing shortages. The DON stated that she, and other nursing staff, usually performed immunization audits to make sure influenza and pneumococcal immunizations were administered and properly documented, but staffing shortages took away from the time allotted for those influenza and pneumococcal audits. Interview on 1/11/2024 at 2:55 PM with the ADM revealed his expectations for influenza and pneumococcal immunizations and documentation for influenza and pneumococcal was that staff followed facility policy to avoid potential adverse health outcomes with residents. The ADM stated efforts in place to ensure accurate administration and documentation of influenza and pneumococcal immunizations were education and monitoring. The ADM stated the failure to provide accurate documentation of influenza and pneumococcal immunization administration, or reasons not to administer, was inconsistency with healthcare audits. Record review of the CDC [recommended adult, 19 years and older, immunization schedule by age group, United States, 2024] indicated the inactivated influenza (killed virus), should be administered [1 dose annually] to people between the ages of [AGE] years old to those equal, or greater, than [AGE] years old. Record review of the CDC [recommended adult immunization schedule by age group, United States, 2024] indicated the pneumococcal immunization should be administered to those equal to, or greater than, [AGE] years old. (Based on age, risk factors, and shared clinical decision making.) Record review of the facility's Influenza Vaccine Policy, dated August 2016, reflected (1) between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contradicted or the resident or employee has already been immunized; (4) prior to the vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676213 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hewitt Nursing and Rehabilitation 8836 Mars Dr Hewitt, TX 76643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few vaccine. Provisions of such education shall be documented in the resident's medical record; (5) for those who received the vaccine, the date of the vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record; (6) residents refusal of the vaccine shall be documented on the 'informed consent for influenza vaccine' and placed in the resident's medical record; (9) only inactivated influenza vaccine will be offered to residents; and (10) resident's may obtained their influenza vaccine from their personal physicians . Documentation of previous vaccination should be provided to the facility. Record review of the facilities Pneumococcal Vaccine Policy, dated August 2016, reflected (1) prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contradicted or the resident has already been vaccinated; (2) assessments of pneumococcal vaccination shall be conducted within five working days of the residents admission if not conducted prior to the admission; (3) before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and educating regarding the benefits and potential side effects of the pneumococcal vaccine; (4) pneumococcal vaccines will be administered to residents per our facility's physician-approved pneumococcal vaccination protocol; (5) residence or resident representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each residence medical record indicating the date of the refusal of the pneumococcal vaccination; and (7) administration of the pneumococcal vaccines, or revaccination, will be made in accordance with current CDC recommendations at the time of the vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676213 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hewitt Nursing and Rehabilitation 8836 Mars Dr Hewitt, TX 76643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to implement their policy to ensure the resident's, or their RP, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 2 of 5 residents (RES #2 and RES #4) who were reviewed for immunizations. 1. The facility failed to document RES #2's medical records for having had received education, whether by self or with RP, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. 2. The facility failed to document RES #4's medical records for having had received education, whether by self or with RP, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Findings include: Record review of RES #2's AR, dated 1/11/2024, reflected RES #2 was an [AGE] year-old male who was admitted the facility on 7/26/2023. He was diagnosed with Type -2 Diabetes (which was a condition that impeded the body's ability to use sugar as fuel) and a Displaced Intertrochanteric Fracture, Right Femur (which was a common type of hip fracture.) Record review of RES #2's Quarterly MDS, dated [DATE], indicated Section C., Cognitive Patterns, that RES #2 had a BIMS Score of 12. A BIMS Score of 12 indicated RES #2 had moderate cognitive impairment. Record review of RES #2's medical records, listed under the Immunizations Tab in PCC, which was the facility's documentation platform, indicated no documentation of Covid-19 immunization education, administration, medical contradiction, or refusal. Record review of RES #4's AR, dated 1/11/2024, reflected RES #4 was a [AGE] year-old male who was admitted the facility on 12/9/2023. He was diagnosed with Metabolic Encephalopathy (which was a chemical imbalance in the blood) and Muscle Weakness. Record review of RES #4's admission MDS, dated [DATE], indicated Section C., Cognitive Patterns, that RES #4 had a BIMS Score of 10. A BIMS Score of 10 indicated RES # had moderate cognitive impairment. Record review of RES #4's medical records, listed under the Immunizations Tab in PCC, which was the facility's documentation platform, indicated no documentation of Covid-19 immunization education, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676213 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hewitt Nursing and Rehabilitation 8836 Mars Dr Hewitt, TX 76643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 administration, medical contradiction, or refusal. Level of Harm - Minimal harm or potential for actual harm Interview and record review on 1/11/2024 at 2:20 PM with the ADON entailed a search of RES #2's medical records in PCC. The search of RES #2's medical records resulted in a facility failure to provide documentation that pertained to (1) RES #2, or their RP, having had received education regarding the benefits and risks, and potential side effects, of the Covid-19 immunization; (2) RES #2 receiving the Covid-19 immunization; or (3) RES #2, having been found ineligible for the Covid-19 immunization due to medical contradiction, or refusal. The search of RES #4's medical records resulted in a facility failure to provide documentation that pertained to (1) RES #4, or their RP, having had received education regarding the benefits and risks, and potential side effects, of the Covid-19 immunization; (2) RES #2 receiving the Covid-19 immunization; or (3) RES #4, having been found ineligible for the Covid-19 immunization due to medical contradiction, or refusal. Residents Affected - Few Interview on 1/11/2024 at 2:30 PM with RES #2 revealed an inability to recall if the facility offered the Covid-19 immunization since his arrival to the facility. Interview on 1/11/2024 at 2:40 PM with RES #4 revealed an inability to recall if the facility offered the Covid-19 immunization since his arrival to the facility. Interview on 1/11/2024 at 2:456 PM with LVN revealed that everyone at the facility was offered the Covid-19 immunizations per facility policy. The immunization was offered to all residents, regardless of whether they were short-term rehab patients or long-term residents. The LVN stated that information pertaining to the Covid-19 immunizations, such as benefit and risk, and potential side effects, was provided to each resident, or their RP, as to make an informed decision. The LVN stated that the facility was supposed to keep consents and refusals for Covid-19 immunizations on file and that the Covid-19 immunization status was found under the immunization section of PCC. Interview and record review on 1/11/2024 at 2:55 PM with the DON revealed the facility failure to document education, receipt, and medical contradiction for Covid-19 immunization was due to staffing shortages. The DON stated that she, and other nursing staff, usually performed immunization audits to make sure Covid-19 immunizations were administered and properly documented, but staffing shortages took away from the time allotted for those Covid-19 immunizations audits. Interview on 1/11/2024 at 2:55 PM with the ADM revealed his expectations for Covid-19 immunizations and documentation for Covid-19 immunizations was that staff followed facility policy to avoid adverse health outcomes with residents. The ADM stated efforts in place to ensure accurate administration and documentation of Covid-19 immunizations were education and monitoring. The ADM stated the failure to provide accurate Covid-19 documentation of Covid-19 immunization administration, or reasons not to administer, was inconsistency with healthcare Covid-19 audits. Record review of the CDC [recommended adult immunization schedule by age group, United States, 2024] indicated the Covid-19 immunization should be provided in the form [one or more doses of updated, 2023 to 2024 formula, vaccine] from young adults at the age of [AGE] years old to those equal, or greater, than [AGE] years old. Record review of the facilities COVID-19 vaccination policy, dated August 2008, indicated (1) the COVID-19 vaccine shall be offered to residents unless the vaccination is medically contradicted or the resident has already been immunized; (3) prior to the vaccination, the resident or legal representative will be provided information and education regarding the benefits and potential side effects (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676213 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hewitt Nursing and Rehabilitation 8836 Mars Dr Hewitt, TX 76643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of the COVID-19 vaccine; (6) the resident's medical record will include documentation, at a minimum, that the resident, or resident representative, was provided education regarding the benefits and potential risks, including rare reactions; each dose of COVID-19 vaccine administered; or if the resident did not receive the COVID-19 vaccine due to medical contradiction or refusal; and (8) if the vaccine is unavailable in the facility, the facility should provide information on obtaining vaccination opportunities to the individual, however it is expected that the facility will provide evidence, upon request, of efforts made to make the vaccine available to residents. Similar to influenza vaccine, if there is a manufacturing delay, the facility should provide evidence of the delay, including efforts to acquire subsequent doses, as necessary. Event ID: Facility ID: 676213 If continuation sheet Page 7 of 7