Health inspection·February 25, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Interview with the MDS nurse on 02/23/24 at 2:40pm, the MDS nurse stated that if a resident used tobacco, it should be reflected on the MDS assessment as well as the care plan. MDS coordinator stated if a resident's MDS assessment or care plan doesn't reflect tobacco use then the resident may have smoking materials in their room when they shouldn't, the resident may not be able to smoke, or possibly burn themselves. Residents Affected - Few Interview with the DON on 02/23/24 at 3:10pm, the DON stated that if a resident was a smoker, then it should be reflected on the MDS and Care Plan. DON stated if a residents MDS did not reflect tobacco use then the care plan would be inaccurate due to the MDS being inaccurate. DON stated a negative outcome of resident that used tobacco but wasn't care plan could be the resident could injure themselves. DON stated it was the MDS coordinator's responsible to accurately complete the MDS assessment as well as the comprehensive care plan. Interview with the ADM on 02/23/24 at 3:20pm, the ADM stated that if a resident was a smoker, then it should be reflected on the MDS and Care Plan. The ADM stated if a residents MDS did not reflect tobacco use then the care plan would be inaccurate due to the MDS being inaccurate and the resident would not receive the care they need. The ADM stated a negative outcome of resident that used tobacco but wasn't care plan could be the resident could injure themselves. The ADM stated the MDS coordinator, or a nurse could complete the comprehensive care plan. The ADM stated the MDS coordinator was responsible for completing the MDS assessment. The ADM stated both the MDS assessment and comprehensive care plan should be completed accurately the ensure the resident was receiving quality care. Record review of the facility's Care Area Assessment 05/2011, reflected Care Area Assessments (CAAs) will be used to help analyze data obtained from the MDS and to develop individualized care plans. CAAs are the link between assessments and care planning. Policy Interpretation and Implementation 1. Triggered Care Areas will be evaluated by the interdisciplinary team to determine the underlying causes, potential consequences, and relationships to other triggered care areas. 2. The Care Area Assessment (CAAs) process consists of the following steps: b. Review the triggered CAAs by doing an in-depth, resident-specific assessment of the triggered condition. 1. History taking; 2. Physical assessment; 3. Gathering of relevant information (Labs, test); and 4. Sequencing of clinically significant events. c. Define the problem(s): (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 2 of 29 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 02/25/2024 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 0641 1. Identify the functional, physical, and/or behavioral implications of the problem(s); Level of Harm - Minimal harm or potential for actual harm 2. Identity the relationship between risk factors, triggers, and problems; 3. Design interventions that address causes, not symptoms; and Residents Affected - Few 4. Establish which items need further assessment or additional review. e. Document interventions FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 3 of 29 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 02/25/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to ensure residents diagnosed as having a mental illness were screened and evaluated prior to admission by the local authority and receive care and services in the most integrated setting appropriate to their needs for 1 of 6 residents reviewed for PASRR screening. (Resident #18). Residents Affected - Few The facility failed to correctly screen on admission [DATE]), and refer, Resident #18 who was diagnosed with mental illness to the appropriate state designated mental health or ID authority for evaluation. This failure placed residents at risk and could affect other residents with psychiatric diagnoses for not being assessed by the local authority and not receiving services to prevent declines. Findings included: Record review of Resident #18's Face Sheet reflected a [AGE] year-old-male had an admission date of 10/13/2023 with diagnoses of Dementia with other behavioral disturbance (impaired ability to remember, think or make decisions along with behaviors of verbal and physical aggression), Obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional), schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and adjustment disorder with anxiety(excessive reaction to stress that involve negative thoughts, strong emotions and changes in behaviors). Record review of Resident #18's MDS assessment dated [DATE] reflected a BIMS score of 13 (reflecting Cognitively Intact) and section I I6000 Psychiatric/Mood Disorder was marked for schizophrenia. Record review of Resident #18's Care Plan dated 01/16/24 reflected Resident #18's was care planned for receiving psychotropic medications d/t schizophrenia, episodes of mood problem AEB psychiatric illness, and episodes of behavior problems r/t poor coping skills, psychiatric illness. Record review of the PASRR Level (1) one screening form for Resident #18 dated 02/09/2023 reflected he had evidence of mental illness and noted yes, PMHx significant for schizophrenia and dementia. Record review of the PASRR Level (1) one screening form for Resident #18 dated 04/13/2023 reflected no evidence of mental illness. During an interview with the MDS nurse on 02/23/24 at 2:40 pm, the MDS nurse stated she was unaware of Residents #18's diagnoses of schizophrenia due to her recently started working at the facility. The MDS nurse stated that if a resident had a diagnosis of schizophrenia, then the PASRR level 1 should be positive. The MDS nurse stated if the PASRR level 1 was incorrect then the resident wouldn't receive the appropriate services such as psych services, a wheelchair, or skilled services. The MDS nurse stated the MDS nurse was responsible for ensure the PASRR level one information was accurate. During an interview with the DON on 02/23/24 at 2:40 pm, the DON stated that if a resident has a diagnosis of Schizophrenia, then the resident would need a PASRR level 2. DON stated if the resident's PASRR level 1 was inaccurate the resident would not receive the specific services or the appropriate care. DON stated it's the MDS coordinators responsible to ensure the PASRR level 1 was correct. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 4 of 29 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 02/25/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the ADM on 02/23/24 at 2:40 pm the ADM stated that if a resident has a diagnosis of Schizophrenia, then the resident would need a PASRR level 2. Administrator stated if the resident's PASRR level one was inaccurate the resident would receive the specific services or the appropriate care. Administrator stated its the MDS coordinators responsible to ensure the PASRR level 1 was correct. Review of the facility's PASRR Clinical Policy, date May 2014, revealed The PASRR level 1 (PL1) screening is designed to identify persons who are suspected of having Mental Illness (MI), Intellectual Disability (ID) of a Developmental Disability (DD) also referred to as Related Conditions. The PASRR Evaluation (PE) is designed to confirm the suspicion of MI, ID, or DD/RC and ensure the individual is placed in the most integrated residential setting receiving the specialized services need to improve and maintain the individual's level of functioning. If the documentation entered on the PASRR Level 1 indicates MI/ID/DD, a PE must be completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 5 of 29 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 02/25/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission that included instructions for providing effective and person-centered care for the resident and met professional standards of quality care for 1 of 6 residents (Resident #228) reviewed for care plans, in that: The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #228 . This deficient practice could place residents at risk of not having their immediate care needs met or not receiving continuity of care. Findings included: Record review of Resident #228's undated Face Sheet reflected a [AGE] year-old female who was admitted on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side (damage to tissues in the brain due to loss of oxygen and blood to the area causing the tissue to die also called a stroke or brain attack with left sided paralysis), hypothyroidism (a thyroid hormone deficiency) , weakness, type 2 diabetes mellitus (elevated blood sugar), and heart failure. Record review of Resident #228's admission assessment dated [DATE] reflected Resident #228 was admitted from the rehab hospital with a diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side she required a wheelchair for mobility, Resident #228 required extensive assistance with bed mobility and total dependance with transfers, dressing, toileting, and bathing. Resident #228 was able to feed herself and requires regular puree diet with thin liquids. Resident #228 was alert and oriented x4 (meaning she was aware of time, event, place, and person) and had a foley catheter present on admission. Record review of Resident #228's's base line care plan initiated 2/09/2024 reflected the care plan was blank and not filled out or signed. Record review of Resident #228's incomplete admission MDS dated [DATE] reflected a BIMS score of 15, indicating cognitively intact. Resident #228 was rated always incontinent with urine and always incontinent with bowel. Resident #228 required a wheelchair for mobility and was substantial max assistance with transfers. In an interview on 02/23/24 at 12:31 PM with RN #A-she states she has been employed for 3 weeks She stated he base line care plan was part of the admission packet. She reported the baseline care plan would have needed to be completed at the time of admission. The negative effects for the resident related to not having a base line care plan would include the risk of a residents needs not being met. In an interview on 02/23/24 at 12:45 PM with the ADON#A she stated the base line care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 6 of 29 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 02/25/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should be completed within a timely manner. She stated the admitting nurse completes the base line care plan upon admission to the facility. The ADON#A reported all nurse managers should check admissions for accuracy. She reported the negative effects on a resident for not having a baseline care plan would have been a lack of communication resulting in staff not knowing how to take care of the resident. In an interview on 02/23/24 at 12:57 PM with the DON she reported the base line care plan was prepopulated when the resident was admitted to the facility. She reported the admitting nurse is responsible for completing the baseline care plan. The DON reported that the ADON is responsible for checking to ensure the admission was completed. The DON monitors the ADON to ensure the admission including the baseline care plan were completed. The DON stated the negative effects on a resident for not having a baseline care plan would be lack of communication related to care of resident. Record review of the facility's Policy and procedure for Care Plans- Baseline dated December 2016 reflected: A baseline plan of care to meet the residents' immediate needs shall be developed for each resident within forty-eight hours of admission. 1) To assure that the residents immediate care needs are met and maintained a baseline care plan will be developed within forty-eight (48) hours of residents' admission. 2) The interdisciplinary team will review the healthcare practitioner's orders (dietary needs medications, routine treatments) and implement a baseline care plan to meet the residents' immediate needs including but not limited to: Initial goals based on admission orders. Physician orders Dietary orders Therapy services Social services and Pre-admission Screening and Resident Review recommendation if applicable 3) The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 4) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 7 of 29 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 02/25/2024 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 0655 The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: Level of Harm - Minimal harm or potential for actual harm The initial goals of the resident Residents Affected - Few A summary of the residents' medication and dietary instructions Any services and treatments to be administered by the facility and personnel acting on behalf of the facility and Any updated information based on the details of the comprehensive care plan, as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 8 of 29 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 02/25/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview observations, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights, which included measurable objectives and time limits to meet a resident's medical, nursing, and mental, and psychosocial needs for 2 of 6 residents (Residents #35 & #44) reviewed for care plans. Resident #35's comprehensive care plan dated 02/20/2024 did not address the resident's fentanyl patch. Resident #44's comprehensive care plan dated 01/26/24 did not address the resident's smoking. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings were: A record review of Resident #35's face sheet reflected Resident #35 was a [AGE] year-old male who was re-admitted to the facility on [DATE] with a diagnosis of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 1 diabetes mellitus with ketoacidosis with coma (when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy), lumbago with sciatica right side (low back pain that shoots down your leg), chronic pain (long standing pain that persists beyond the usual recovery period), lobulated fused and horseshoe kidney (two kidneys fused together at the lower end or base shaping a U), and muscle weakness (reduced muscle strength) Record review of Resident #35's Annual MDS, dated [DATE], reflected Resident 35's BIMS score was 15 which indicated resident 35 is cognitively intact. Record review of Resident #35's Care Plan, dated 02/20/2024, did not address Resident 35's fentanyl patch. Record review of Resident #35's Physician Order, dated 02/23/24 reflected Resident #35 fentanyl patch start date was 05/17/23 and was still a current order. Interview with Resident #35 on 02/22/2024 at 11:25 am, Resident #35 stated she has had the fentanyl patch for about a year. Resident #35 stated that her fentanyl patch for was for pain. A record review of Resident #44's face sheet reflected Resident #44 was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of partial intestinal obstruction (bowel is partly blocked), Pulmonary embolism without acute cor pulmonale (blockage of a pulmonary (lung) artery) Muscle weakness (reduced muscle strength), and Cardiac murmur (a blowing, whooshing, or rasping sound heard during a heartbeat). Record review of Resident #44's Admissions MDS dated [DATE] reflected the resident had a BIMS score of 13 indicating cognitive intactness. The MDS did not reflect Resident #44 used tobacco. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 9 of 29 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 02/25/2024 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 0656 Record Review of Resident #44's care plan dated 01/26/24 did not reflected Resident #44's tobacco use. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's smoking list not dated, revealed Resident #44 was listed as a smoker. Observation on 02/21/2024 at 11:05am, reflected Resident #44 smoked two cigarettes with staff present. Residents Affected - Few Interview with Resident #44 on 02/21/24 at 11:05 am, Resident #44 stated he has been smoking since he has been at the facility. Resident stated he has been at the facility for about a month but was smoking before he came to the facility. Interview with MDS nurse on 02/23/24 at 2:40pm, the MDS nurse stated that if a resident used tobacco, it should be reflected on the MDS assessment as well as the care plan. MDS coordinator stated if a resident's MDS assessment or care plan doesn't reflect tobacco use then the resident may have smoking materials in their room when they shouldn't, the resident may not be able to smoke, or possibly burn themselves. The MDS nursed stated if a resident received an opioid (fentanyl patch) then that should be indicated on the care plan just like psychotropic medication would be care planned. The MDS nurse stated if resident care plans and MDS was not accurate then they might not receive the appropriate care. Interview with DON on 02/23/24 at 3:10pm, the DON stated that if a resident was a smoker, then it should be reflected on the MDS and Care Plan. DON stated if a residents MDS did not reflect tobacco use then the care plan would be inaccurate due to the MDS being inaccurate. DON stated a negative outcome of resident that used tobacco but wasn't care plan could be the resident could injure themselves. DON stated if a resident receives a fentanyl patch that should be care planned. DON stated if the resident fentanyl patch was not care planned then the resident may not receive the appropriate care. DON stated it was the MDS coordinator's responsible to accurately complete the MDS assessment as well as the comprehensive care plan. Interview with ADM on 02/23/24 at 3:20pm, the ADM stated that if a resident was a smoker, then it should be reflected on the MDS and Care Plan. The ADM stated if a residents MDS did not reflect tobacco use then the care plan would be inaccurate due to the MDS being inaccurate and the resident would not receive the care they need. The ADM stated a negative outcome of resident that used tobacco but wasn't care plan could be the resident could injure themselves. The ADM stated that if a resident received a fentanyl patch that should be care plan but if it wasn't then the resident may not receive the appropriate care. The ADM stated the MDS coordinator, or a nurse could complete the comprehensive care plan. The Administrator stated the MDS coordinator is responsible for completing the MDS assessment. The ADM stated both the MDS assessment and comprehensive care plan should be completed accurately the ensure the resident was receiving quality care. Record review of the facility's Care Plans, Comprehensive Person-Centered 12/2016, reflected A comprehensive, person-centered care plan that includes measurable objective and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 10 of 29 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 02/25/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived for a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The IDT include: A. The attending Physician; B. A registered nurse who has responsibility for the resident; C. A nurse aide who has responsibility for the resident; D. A member of the food and nutrition services staff; E. The resident and the resident's legal representative (to the extent practicable); and F. Other appropriated staff or professionals as determined by the resident's needs or as requested by the resident. 7. The Care planning process will: A. Facilitate resident and/or representative involvement; B. Include an assessment of the resident's strengths and needs; and C. Incorporate the resident's personal and cultural preferences in developing goals of care. 8. The Comprehensive, person care plan will: A. include measurable objectives and time limits: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 11 of 29 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 02/25/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few B. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being: C. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment: D. Describe any specialized services to be provided as a result of PASARR recommendations: I. Reflect treatment goals, timetables and objectives in measurable outcomes; K. Identify the professional services that are responsible for each element of care; 13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition change. 14. The interdisciplinary Team must review and update the care plan: A. When there has been a significant change in the resident's condition: B. When the desired outcome is not met: C. When the resident has been readmitted to the facility from a hospital stay: and D. At least quarterly, in conjunction with the required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 12 of 29 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 02/25/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents who were unable to conduct activities of daily living received the necessary services to maintain acceptable grooming and personal hygiene for 2 of 8 residents (Resident #7 and Resident #40) reviewed for ADL Care. Residents Affected - Some 1. The facility failed to provide Resident #7 with nail care, which resulted with some nails protruding past the fingertip, some nails gagged, and 8 of 10 digits had collection of dirt, stain, or debris under the nail on 02/20/2024. 2. The facility failed to provide Resident #40 with nail care, which resulted with nails protruding past the fingertip for all 10 digits. Resident's toenails on her left foot extended .5 an inch on two toes, which had begun to split and curl on 02/20/2024. This failure placed residents at risk of diminished quality of life, embarrassment, and self-consciousness of their appearance. Findings included: 1. Record review of Resident #7's AR, dated 2/20/2024, reflected a [AGE] year-old who was admitted to the facility on [DATE]. He was diagnosed with chronic kidney disease (which was a gradual loss of kidney functions;) chronic diastolic heart failure (which led to decreased blood flow;) and, unspecified lack of coordination (which was a medical code that denoted difficulties with body movements.) Record review of Resident #7's Quarterly MDS, dated [DATE] reflected Section C., Cognitive Patterns, indicated the resident had a BIMS Score of 15. A BIMS score of 15 indicated the resident was not cognitively impaired. Section GG., Functional Abilities and Goals; Resident #7 required substantial/maximum assistance for personal hygiene (which meant the helper did more than half of the effort.) Record review of Resident #7's CP reflected a [Focus] for the resident having had potential impairment to skin integrity R/T fragile skin and anti-coagulation therapy, initiated 2/6/2023. The [Goal] was to be free from injury through the review date, revised 1/26/2024. The [Intervention] was for nursing staff to help Resident #7 avoid scratching and to keep fingernails short, initiated 2/6/2023. A second [Focus] for the resident having had ADL self-performance deficit R/T to limited mobility and musculoskeletal impairment, initiated on 10/6/2023. The [Goal] was to maintain current level of function in personal hygiene through the review date, initiated on 10/6/2023. The [Intervention] was for nursing staff was to check nail length and trim and clean on bath day and as necessary, initiated 10/6/2023. 2. Record review of Resident #40's AR, dated 2/20/2024, reflected a [AGE] year-old woman who admitted to the facility on [DATE]. She was diagnosed with Type 2 diabetes (which was a condition that disrupted the way her body used sugar for fuel;) chronic diastolic heart failure (which led to decreased blood flow;) discoid lupus erythematosus (which was an autoimmune disease that caused widespread inflammation;) and chronic kidney disease (which was a gradual loss of kidney function.) Record review of Resident #40's Quarterly MDS, dated [DATE], reflected Section C., Cognitive Patterns, indicated the resident had a BIMS Score of 5. A BIMS score of 5 indicated the resident had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 13 of 29 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 02/25/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some severe cognitive impairment. Section GG., Functional Abilities and Goals, indicated the resident required substantial/maximum assistance with personal hygiene (which meant the helper did more than half of the effort.) Record review of Resident #40's CP reflected a [Focus] for the resident having had potential impairment to skin integrity R/T fragile skin and discoid lupus, initiated 6/19/2023. The [Goal] was to be free from injury through the review date, revised 1/5/2024. The [Intervention] was for nursing staff to help Resident #40 avoid scratching and to keep fingernails short, initiated 12/24/2023. A second [Focus] for the resident was evidenced by chronic kidney disease, initiated 8/12/2021. The [Goal] was to be free from signs and symptoms of dehydration through the review date, revised on 1/5/2024. The [Intervention] for nursing staff was to monitor foot care needs and cut long nails, initiated on 11/16/2023. Record review of Resident #40's [Order Summary Report] reflected an active order for [Podiatry Care,] dated 6/7/2023. Record review of Resident #40's [Skin Monitoring: Comprehensive CNA Shower Review,] dated 2/13/2024, indicated Resident #40 needed her toenails cut. [Skin Monitoring: Comprehensive CNA Shower Review,] dated 2/17/2024, indicated Resident #40 needed her toenails cut. [Skin Monitoring: Comprehensive CNA Shower Review,] dated 2/20/2024, indicated Resident #40 needed her toenails cut. Observations and interview on 02/20/24 at 02:46 PM with Resident #40 reflected 4 pieces of food on her chest. Her gown, at the top of her chest, was greasy. Her fingernails, on both hands, were long and each had a collection of dirt on the underside. Resident #40 thought it was time for her nails to be cut. She had accidently scratched herself with her fingernails before and it was not pleasant. She stated, staff had not been around to cut them for a long time. She denied any pain because of her fingernails. Observations and interview on 02/20/24 at 03:26 PM with Resident #7's reflected his fingernails, on both hands, were unevenly trimmed and gagged; Each fingernail, not including the thumbs, contained dirt on the underside of the nail. 2 of his fingers on his right hand and 3 fingers on his left hand had red stains. Resident #7 stated staff have not been by recently to trim my nails. The red stains on his fingertips were smears of blood that remained after he picked at small sores on his right and left arms. He denied any pain. Observation and interview on 02/21/24 at 07:28 AM with Resident #40 reflected her fingernails, on both hands, were long and each had a collection of dirt on the underside. The skin on her right foot was dry. The skin on her left foot was dry and 3 of her toenails were long enough to curl at the end. Resident #40 stated the people who came to look at her feet had not been by to see her in a while. She denied pain associated with her fingernails or her toenails. Observations and interview on 02/21/2024 at 9:37 AM with Resident #7's reflected his fingernails, on both hands, were unevenly trimmed and gagged; Each fingernail, not including the thumbs, contained dirt on the underside of the nail. Resident #7 picked at small sores in his right arms, which left a residue of blood on his fingers. He wanted better care from the staff. Interview and observation on 02/22/24 at 9:16 AM with Resident #40 revealed someone had trimmed and painted her fingernails since the last observation on 02/21/24 at 07:28 AM. Her fingernails were appropriately trimmed and were painted pink; her feet, however, were the same as the last observation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 14 of 29 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 02/25/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on 02/21/24 at 07:28 AM; The skin on her right foot and left foot was dry and 3 of her toenails on her left foot were long enough to curl at the end. She felt better about herself, and her appearance, with her nails done. Interview and observation on 02/22/24 at 2:10 PM with LVN Z revealed Resident #7 received medication and cream for his arms because he itched, and he scratched his arms often. LVN Z visually inspected Resident #7s fingernails during the interview, who agreed Resident #7 needed nail care; She stated she would get someone to provide his nail care. Interview and observation on 02/23/24 at 8:34 AM with Resident #7 revealed his nails had been filed even but were still dirty with red stains. He had his itch cream on his bedside table. Interview on 2/23/2024 at 2:28 PM with CNA O revealed nail care was important for the residents because residents with long, or gagged, fingernails had a greater risk of scratching themselves, as well as scratching an employee. Long nails, or gagged nails, caused deep scratches and cuts, especially those residents with fragile skin. When she observed fingernails past the length of the fingertip, or gagged nails, she reported those concerns to the charge nurse. If the nails were dirty, CNA O cleaned them with warm soapy water and a nail brush, to prevent the spread of infection. The CNAs filled out a skin condition form during a resident's shower/bath, which had an area to check off for toenail care. The forms were provided to the charge nurse for review and assessment. Residents identified having long toenails were treated by the licensed nursing staff, or they would schedule a podiatry appointment. Interview on 2/23/2024 at 2:50 PM with LVN Y revealed it was important to keep resident's fingernails trimmed, and cleaned, to protect from cuts, bleeding, and the spread of infections. CNAs were trained to observe and report all residents who required fingernail care as well as documenting the need for toenail care on the resident's shower sheet. If a resident needed nail care the licensed nursing staff would assess, treat, or call for a podiatry consult. Interview, observation, and record review on 2-23-2023 at 4:00 PM with the ADON A revealed nail care was important to avoid scratches, scrapes, and reduce the spread of infection. The ADON stated the procedure to identify the need for nail care was for CNAs to observe and identify the need for nail care and to and report those needs to the charge nurse. As well, CNAs were trained to observe, and report, the need for toenail care on the resident's shower sheet. The ADON A was provided Resident #40's last three shower sheet, dated 2/13/2024, 2/17/2024, and 2/20/2024. Each shower sheet indicated Resident #40 had long toenails. The ADON made a visual inspection of Resident #40's toenails, who stated Resident #40 required toenail care, they needed to be trimmed; The ADON made a visual inspection of Resident #7's fingernails, who stated Resident #7 required more fingernail care, they needed to be cleaned. The ADON stated the reason Resident #40 and Resident #7 did not receive nail care was a failure for nursing staff to communicate the residents' needs and follow through with shower sheet findings. Interview on 2/25/2023 at 10:15 AM with the ADM revealed the facility had a policy for nail care and a process to report resident's nail care needs to the nursing staff. The ADM expected his staff to follow the procedure so the residents could receive the care. The facility's failure to provide the appropriate nail care fell on the nursing staff not following with reports or documentation. Record Review of the facility's [Care of Fingernails/Toenails] Policy, dated April 2007, reflected (1) nail care included daily cleaning and regular trimming; (2) proper nail care aided in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 15 of 29 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 02/25/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm prevention of skin problems around the nail bed; (4) trimmed and smooth nails prevented the resident from accidentally scratching themselves; (5) watch for, and report, any changes of skin color, poor circulation, cracking on the skin, or swelling; and, (6) to stop and report evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease to the nursing supervisor. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 16 of 29 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 02/25/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #228) reviewed for incontinent care. Facility failed to evaluate Resident #228 for removal of newly placed indwelling catheter or establish a rational for original placement to establish a need for an indwelling foley catheter upon admission. This deficient practice could place residents at risk by exposing them to care that could lead to infection, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: Record review of Resident #228's undated Face Sheet reflected a [AGE] year-old female who was admitted on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side (damage to tissues in the brain due to loss of oxygen and blood to the area causing the tissue to die also called a stroke or brain attack with left sided paralysis), hypothyroidism (a thyroid hormone deficiency) , weakness, type 2 diabetes mellitus (elevated blood sugar), and heart failure. Record review of Resident #228's admission assessment dated [DATE] reflected Resident #228 was admitted from the rehab hospital and had a foley catheter present on admission. Record review of Resident #228's incomplete admission MDS dated [DATE] reflected a BIMS score of 15, indicating cognitively intact. Resident #228 was rated always incontinent with urine. Record review of Resident #228s History and Physical dated 02/13/24 reflected Resident #228s Genitourinary (urinary) system had been reviewed and was normal/negative indication she had no failures within her urinary system. In an interview on 02/20/24 at 3:16 PM with Resident #228 revealed she has been in the facility for 3 weeks. Resident #228 reported she has had the foley catheter since she was at the hospital. She reported the foley catheter was really bothering her with irritation. Resident #228 revealed she has never had to have a foley catheter in the past. Resident #228 stated would be discharged home soon. In an interview on 02/23/24 at 12:31 PM with RN #C-reflected he has been employed for 3 weeks at the facility. RN #C reported a resident admitted with a Foley catheter would need justification for the use or need for the catheter. RN #C reported Catheters are never used for convenience. Nurses would need to call physician to see if the catheter could be discontinued or if the facility could possibly do a voiding trial to determine if the resident would have needed to be seen by a urologist. RN #C reported the risk factors for having had a foley catheter would include infection, trauma, and urinary dependence. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 17 of 29 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 02/25/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/23/24 at 12:45 PM with the ADON #A she revealed it was her expectation for a resident who admits with a foley catheter would have been to contact the physician for trial for discontinuation of the foley catheter or get resident to urology. The ADON#A reported the facility would need to find out why resident would need a foley catheter, ask nurse practitioner to evaluate the resident for appropriate diagnosis. The ADON#A reported she is not sure there has been any training for foley catheters. The ADON#A reported the negative effects would of having a foley catheter in place would have been urinary tract infection, trauma, worsening of urinary incontinence. The ADON#A reported that nurse managers responsible for following up on orders for foley catheters and further investigation of why a resident would need one. In an interview on 02/23/24 at 12:57 PM with the DON revealed for residents admitted with a foley catheter the admitting nurse would have needed to contact the nurse practitioner or the physician to obtain an appropriate diagnosis or receive an order to remove foley. The goal would have been to find out why the foley catheter was needed. The DON revealed the resident would have needed a voiding trial or possible referral to urology for further investigation and assessment as to any abnormalities causing urinary retention. The DON reported the negative effects for a resident maintaining long term use of a foley catheter would be infection. The DON stated the ADON reviews admissions and admission orders, the DON supervises all ADONs. Record review of the facility's policy and procedure for Urinary Continence and Incontinence - Assessment Management Dated April 2010 #14 - If a resident /patient is admitted from the hospital with a newly placed indwelling catheter the attending physician and staff will evaluate the potential for removing it depending on the current condition and the rational for its original placement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 18 of 29 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 02/25/2024 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.for 1 out of 6 residents (Resident # 234) reviewed for behaviors. Residents Affected - Few The facility failed to provide appropriate behavioral health services and/or interventions to prevent or improve the depressive behaviors of Resident # 234. This deficient practice could place residents at risk for causing a delay in receiving appropriate services and a deterioration in the resident's psychosocial well-being. Findings include: Record review of Resident #234's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #234 had diagnoses which included heart attack, metabolic encephalopathy (a chemical imbalance of the brain causing confusion), anemia (low red blood cells), dementia and type 2 diabetes (elevated blood sugar). Record review of Resident #234 admission MDS assessment, dated 2/5/24, reflected Resident #234 had a BIMS score of 8 which indicated Resident #234 was cognitively impaired. Section D Mood Interview of the same MDS reflected Resident #234 did not indicate any signs or symptoms of depression. Resident #234 required substantial max assistance with personal hygiene upper and lower body dressing. Record review of Resident #234s' care plan, initiated 2/1/24, reflected Resident #234 was taking an antidepressant medication with a goal to remain free from signs and symptoms of depression. Interventions listed reflected the facility would administer medications as ordered. Observe/document for side effects and effectiveness. Arrange psychiatric consult follow up as indicated. Record review of a LVN Ws' progress note, dated 2/5/24 at 9:30 AM, reflected Resident #234's family member brought a medication list from home and requested Amitriptyline (an antidepressant) be given as he had previously been on the medication at home. Record review of Resident #234s order recap report, dated 2/1/24-2/22/24, reflected the resident had an order received on 2/5/24 for Amitriptyline Oral Tablet 150 Milligrams Amitriptyline HCl) Give 2 tablet by mouth every morning and at bedtime for depression. Record review of the Medication Administration log for February 2024 reflected Resident #234 received 300 mg of amitriptyline by mouth on 2/6/24 at 9 AM. Record review of Resident #234 census reflected Resident #234 was sent to the hospital on 2/6/24 and readmitted to the facility 2/13/24. In a record review of the after-visit summary, dated 2/13/24, reflected Resident #234 hospital admitting diagnosis was acute drug overdose, accidental or unintentional initial encounter, The Hospital instructions were to stop amitriptyline 10mg . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 19 of 29 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 02/25/2024 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete In an interview on 02/21/24 at 10:32 AM with the NP revealed the facility notified the NP of a concern due to Resident #234's increased lethargy. The NP reported Resident #234's family member had concerned the resident was over sedated. The NP reported she asked if Resident #234 had his morning medications. The NP stated she pulled his medication profile and reviewed his medications, she stated she questioned the orders that were input on Amitriptyline 150 mg 2 tablets twice daily. The NP stated the order written by LVN W should have been for 10 mg by mouth at bedtime and there was a mistake in the order transcription. Resident #234 received 1 dose of 300 mg of amitriptyline on 2/6/24. The NP reported she ordered the resident to be sent to the hospital for evaluation of adverse effects related to medications error. Event ID: Facility ID: 676213 If continuation sheet Page 20 of 29 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 02/25/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure based on a comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat specific condition as diagnosed and documented in the clinical record for 1 of 6 residents (Resident #230) reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #230's prescribed Bupropion (an antidepressant) was administered to treat a specific diagnosis . This failure could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings include: Record review of Resident #230's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #230 had diagnoses which included: sepsis unspecified organism, hyperlipidemia (elevated cholesterol), essential hypertension (high blood pressure), Atherosclerotic heart disease of native coronary artery without angina pectoris (hardening of the arteries), peripheral vascular disease (lack of blood flow throughout the legs), cirrhosis of the liver, (Chronic liver damage) and spondylosis without myelopathy or radiculopathy (narrowing of the spin) . Record review of Resident #230's incomplete admission MDS assessment, dated 2/20/24, reflected Resident #230 had a BIMS score of 14, which indicated Resident #230 was cognitively intact. Resident #230 refused to answer Section D Mood Interview of the same MDS. Record review of Resident #230's care plan, initiated 2/17/24, reflected Resident #230 was not care planned for any antidepressant medications. In a record review of Residents #230's progress notes, dated 2/17/24 at 12:36 PM, reflected Resident #230 was hallucinating and had confusion. Record review of the Nursing Home order summary report for Resident #230 reflected an order for Bupropion HCI (XL) oral tablet extended release 24-hour 150 mg 1 tablet by mouth one time a day for indications of depression. No active diagnosis was reflected on the order. Record review of Resident #230 miscellaneous records reflected there was no medication consent on file for Bupropion. Record review of hospital medical records referral, dated 1/27/24, reflected Resident #230 had the following active diagnosis: sepsis (a blood infection), hypertensive disorder (high blood pressure), hyperlipidemia (elevated cholesterol), obesity, hydronephrosis of the right kidney (swollen kidneys). In an interview on 02/23/24 at 12:45 PM with ADON A, she reported the expectation was a consent and diagnosis for any psychotropic medication would be obtained upon admission. This was part of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 21 of 29 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 02/25/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission process. The negative effects for not obtaining a consent or diagnosis for an antidepressant/ psychotropic would be lack of information, because the resident and RP would not be aware of side effects of medication. Lack of education and information related to medications. In an interview on 02/23/24 at 12:57 PM, the DON reported her expectation was consents and diagnosis should be completed on admit. The DON reported nurses were responsible for consent and diagnosis and nurses were responsible for education for psychotropic medications. Negative effects for the resident would be the family and resident were not able to make informed decision related to the type of medication and a lack of education related to side effects of the medication. The ADONs were responsible for follow up on the admission packets including reviewing diagnosis and consents. The DON was responsible for monitoring and ensuring the process was followed. Record review of the facility's policy and procedure for Medication Utilization and Prescribing, dated July 2016, reflected when a resident is prescribed in response to an identified problem, condition, or risk , the physician and staff will identify the indications (conditions or problems for which it is being given or what the medication is supposed to do or prevent), considering the residents age, condition, risks, health status, and existing medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 22 of 29 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 02/25/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) Dietary staff failed to effectively reseal, label and date items in the walk-in refrigerator. 2) Dietary staff failed to effectively reseal, label and date items in the walk-in freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During the initial tour of the kitchen on 02/20/2024 at 08:37 AM the following was observed: The walk-in freezer contained a bag labeled ravioli in a clear plastic bag with no dates documented. The walk-in freezer contained a bag labeled hamburger patties in a clear plastic bag with no dates documented. The walk-in refrigerator contained a bag labeled shredded cheese in a clear plastic bag with a prepared date of 02/16/24 with no use by date documented. The walk-in refrigerator contained a bag labeled mozzarella cheese in a clear plastic bag that was loosely opened and exposed to the air. Interview with the Dietary Manager on 02/20/24 at 9:00 AM, the dietary manager stated the cooks knew to discard opened items within 3 days of opening them. The Dietary Manager stated if food was not dated the food would be compromised. The Dietary Manager stated food items could be old, be molded, or smell if not appropriately labeled with a received, opened, and used by dates. The Dietary Manager stated the cooks were responsible for appropriately labeling the opened with items with a received, opened, and used by dates. The Dietary manager stated the walk-in refrigerator/freezer had signage instructing staff to not leave food in it opened over 3 days . Interview with [NAME] A on 02/20/24 at 9:05 AM, [NAME] A stated if items were opened, the item should be placed in a ziploc bag and labeled with an opened date and used by date. [NAME] A stated opened items should be discarded after 3 days. [NAME] A said food items that did not have a received, opened, and used by date should be thrown away. [NAME] A stated if the food items were not labeled with dates, then the food could be spoiled or old. [NAME] A stated if residents were served old food, they could get sick. [NAME] A stated it was the kitchen staff's responsibility to make sure food was labeled with the received, opened, and used by dates . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 23 of 29 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 02/25/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Interview with the ADM on 02/23/24 at 3:20 PM, the ADM stated foods in the refrigerator and freezer should have been labeled appropriately with the received by, opened, and used by dates. The ADM said if food was not labeled appropriately then the food could be spoiled, and the facility could possibly serve spoiled food to the residents. The ADM stated whoever opened the items should appropriately date and label it. Residents Affected - Many Record review of the facility's Food Storage: Cold Foods, dated 04/2018, reflected All time/temperature control for Safety (TCS ) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures 5. All food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . A record review of the FDA's 2022 Food Code reflected the following: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 24 of 29 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 02/25/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each residents bedside and the toilet and bathing facilities for 3 of 8 residents (Resident #41, Resident #10 and Resident #51) reviewed for environment. Residents Affected - Some 1. The facility failed to ensure Resident # 41's call light pull string, in the bathroom, was from free from entanglements and extended to its intended length and was reachable from lying on the floor. 2. The facility failed to ensure Resident # 10's call light pull string, in the bathroom, was from free from entanglements and extended to its intended length and was reachable from lying on the floor. 3. The facility failed to ensure Resident # 51's call light pull string, in the bathroom, was from free from entanglements and extended to its intended length and was reachable from lying on the floor. These failures could place residents at risk for having their needs unmet. Findings include: 1. Record review of Resident #41's AR, dated 2/20/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. She was diagnosed with hemiplegia and hemiparesis (which was condition that involved one-sided paralysis;) Diabetes Mellitus Type 2 (which was condition of the body's inability to use sugar for fuel;) and unspecified abnormalities of gait (which was a change in Resident #41's walking pattern.) Record review of Resident #41's CP reflected a Focus, revised on 10/1/2023, evidenced by risk for falls R/T decreased mobility. The Goal, revised on 1/22/2024, indicated the resident would not sustain any serious injuries R/T falls. The Intervention, revised on 2/28/2022, delegated CNAs to ensure Resident #41 was wearing appropriate footwear when mobilizing in her wheelchair, and ensuring the resident's call light was within reach to call for assistance. Record review of Resident #41's Annual MDS, dated [DATE], reflected Section C., Cognitive Patterns; Resident #41 had a BIMS Score of 12, which indicated Resident #41 had moderate cognitive impairment. Section GG., Functional Abilities and Goals; Resident had impairment on one side of their upper extremities (shoulder, elbow, wrist, and hand) and one side of their lower extremities (hip, knee, ankle, and foot.) Resident #41 utilized a wheelchair for ambulation. Resident #41 required substantial/maximal assistance for toileting hygiene, personal hygiene, toilet transfer, and tub/shower transfer, which meant the helper did more than half the effort. Section H., Bladder and Bowel indicated Resident #41 was always incontinent of bladder and bowel. Observation on 02/20/24 at 11:01 AM of Resident #41's call light pull string in Resident #41's bathroom revealed it was not hanging freely from the junction box in the direction of the floor. The call light pull string was connected to a junction box and attached was a long string that was supposed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 25 of 29 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 02/25/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to hang down towards the direction of the floor. The call light pull string was knotted 4 times. The amount of string utilized in the 4 knots took slack from the call light pull string. Using a measuring tool from a state issued iPhone 13, the end of the call light pull string was 25 inches from the floor. Observation on 02/21/24 at 07:22 AM of Resident #41's call light pull string in Resident #41's bathroom reflected it was not hanging freely from the junction box in the direction of the floor. The call light pull string was connected to a junction box and attached was a long string that was supposed to hang down towards the direction of the floor. The call light pull string was knotted 4 times. The amount of string utilized in the 4 knots took slack from the call light pull string. Using a measuring tool from a state issued iPhone 13, the end of the call light pull string was 25 inches from the floor. Observations on 2/22/2024 at 8:45 AM reflected Resident #41's call light pull string in Resident #41's bathroom was not hanging freely from the junction box in the direction of the floor. The call light pull string was connected to a junction box and attached was a long string that was supposed to hang down towards the direction of the floor. The call light pull string was knotted 4 times. The amount of string utilized in the 4 knots took slack from the call light pull string. The knots were untied, and another measurement was taken; the end of the call light pull string was 25 inches from the floor. 2. Record review of Resident #10's AR, dated 2/20/2024, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. He was diagnosed with Cardiac Arrhythmia, unspecified (which was an irregular heartbeat;) Unsteadiness on Feet (which was a temporary condition of an injury;) and, Unspecified fall, subsequent encounter (which was a medical code evidenced by an external cause of accidental injury.) Record review of Resident #10's CP reflected a Focus, initiated on 9/6/2023, was evidenced by a history of falls. The [Goal,] revised on 10/14/2023, stated the resident would resume usual activities without further incident. The [Intervention,] revised on 12/8/2023, delegated nursing staff to determine possible causes of the post falls and implement proper interventions. A second Focus, revised on 10/23/2023, was evidenced by falls R/T poor communication, comprehension and unsteady gait. The Goal, revised on 10/14/2023, stated the resident would not sustain falls with injury. The Intervention, initiated on 7/14/2023, delegated nursing staff to reinforce the need for the resident to call for assistance. Record review of Resident #10's Quarterly MDS, dated [DATE], reflected Section C., Cognitive Patterns; Resident #10 did not participate in a BIMS Score assessment, rather was assessed by staff having resulted in the resident's cognition level categorized as severely impaired. Section GG., Functional Abilities and Goals; Resident had no impairment for both upper (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot.) Resident #10 utilized a wheelchair for ambulation. Resident #10 required partial/moderate assistance for toileting hygiene, shower/bathe self, and personal hygiene. Partial/moderate assistance indicated the helper did less than half the effort. Resident #10 required substantial/maximal assistance for toilet transfer. Substantial/maximal assistance indicated the helper provided more than half the effort. Section H., Bladder and Bowel indicated Resident #10 was always incontinent of bladder and always incontinent of bowel. Record review of Resident #10's progress note, dated 11/19/2023, reflected the resident tried to ambulate on his own; he made it to the doorway and fell. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 26 of 29 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 02/25/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observations on 02/20/24 at 10:45 AM of Resident #10's call light pull string in Resident #10's bathroom was not hanging freely from the junction box in the direction of the floor. The call light pull string was connected to a junction box and attached was a long string that was supposed to hang down towards the direction of the floor. The call light pull string was wrapped and knotted 1 time around a fixed support bar affixed to the wall next to the toilet. The activation of the alarm to alert staff was inoperable when pulled from the end of the string that extended past the wrap, the knot, and the fixed support bar. Using a measuring tool from a state issued iPhone 13, the end of the call light pull string was 23 inches from the floor. Observations on 02/21/24 at 07:25 AM of Resident #10's call light pull string in Resident #10's bathroom revealed it was not hanging freely from the junction box in the direction of the floor. The call light pull string was connected to a junction box and attached was a long string that was supposed to hang down towards the direction of the floor. The call light pull string was wrapped and knotted 1 time around a fixed support bar affixed to the wall next to the toilet. The activation of the alarm to alert staff was inoperable when pulled from the end of the string that extended past the wrap, the knot, and the fixed support bar. Using a measuring tool from a state issued iPhone 13, the end of the call light pull string was 23 inches from the floor. Observation on 2/22/2024 at 8:50 AM reflected Resident #10's call light pull string in Resident #10's bathroom was not hanging freely from the junction box in the direction of the floor. The call light pull string was connected to a junction box and attached was a long string that was supposed to hang down towards the direction of the floor. The call light pull string was wrapped and knotted 1 time around a fixed support bar affixed to the wall next to the toilet. Using a measuring tool from a state issued iPhone 13, the end of the call light pull string was 23 inches from the floor. 3. Record review or Resident #51's AR, dated 2/20/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. She was diagnosed with Rhabdomyolysis (which occurred when damaged muscle tissue released its proteins and electrolytes into the blood;) Atrial Fibrillation (which was a disease of the heart characterized by irregular and often faster heartbeat;) and, unspecified lack of coordination (which was general lack of coordination.) Record review of Resident #51's CP reflected a Focus, initiated on 7/31/2023, evidenced by high risk for falls. The Goal, revised on 7/31/2023, indicated resident would be free from falls. The Intervention, initiated on 7/31/2023, delegated CNA staff to ensure the resident was wearing appropriate footwear when ambulating or mobilizing in a wheelchair; and to ensure the resident's call light was working and within reach / encourage the resident to use it for assistance. Record review of Resident #51's Annual MDS, dated [DATE], reflected Section C., Cognitive Patterns; Resident #51 had a BIMS Score of 15, which indicated Resident #51 did not have cognitive impairments. Section GG., Functional Abilities and Goals; indicated the Resident had no impairment for both upper (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot.) Resident #51 utilized a wheelchair for ambulation. Resident #51 required partial/moderate assistance for toileting hygiene, shower/bathe self, and personal hygiene. Partial/moderate assistance indicated the helper did less than half the effort. Resident #10 required substantial/maximal assistance for toilet transfer. Substantial/maximal assistance indicated the helper provided more than half the effort. Section H., Bladder and Bowel indicated Resident #10 was always incontinent of bladder and always incontinent of bowel. Section GG., Functional Abilities and Goals; Resident #51 required supervision or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 27 of 29 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 02/25/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some touching assistance for shower/bathe self and personal hygiene. Substantial/maximal assistance indicated the helper did more than half the effort. Resident #51 required setup assistance for tub/shower transfer. Setup assistance indicated the helper set up or cleaned up prior to, or following, the activity. Section H., Bladder and Bowel indicated Resident ##51 was frequently incontinent of bladder and bowel. Observations 02/20/24 at 01:27 PM of Resident #51's call light pull string in Resident #51's bathroom revealed it was not hanging freely from the junction box in the direction of the floor. The call light pull string was connected to a junction box and attached was a long string that was supposed to hang down towards the direction of the floor. The call light pull string was knotted 10 times. The amount of string utilized in the 10 knots took slack from the call light pull string. Using a measuring tool from a state issued iPhone 13, the end of the call light pull string was 27.5 inches from the floor. Observation on 02/21/24 at 07:41 AM reflected Resident #51's call light pull string in Resident #51's bathroom revealed it was not hanging freely from the junction box in the direction of the floor. The call light pull string was connected to a junction box and attached was a long string that was supposed to hang down towards the direction of the floor. The call light pull string was knotted 10 times. The amount of string utilized in the 10 knots took slack from the call light pull string. Using a measuring tool from a state issued iPhone 13, the end of the call light pull string was 27.5 inches from the floor. Interview and on 2/21/2024 at 7:45 AM with Resident #51 revealed she has used the toilet in the room's bathroom. She wondered why the call light pull string was so long and was surprised to learn it was supposed to hang to the floor in case of a fall. Resident #51 stated she would be upset if she fell in the bathroom and could not reach the call light pull string. Observation on 2/22/2024 at 9:00 AM reflected Resident #51's call light pull string in Resident #51's bathroom was not hanging freely from the junction box in the direction of the floor. The call light pull string was connected to a junction box and attached was a long string that was supposed to hang down towards the direction of the floor. The call light pull string was knotted 10 times. The amount of string utilized in the 10 knots took slack from the call light pull string. Using a measuring tool from a state issued iPhone 13, the end of the call light pull string was 27.5 inches from the floor. Interview and observation on 2/22/2024 at 11:35 AM with CNA P revealed staff were trained to ensure each resident knew how to utilize the call system located in the resident's bathroom. If a resident could not reach the call light, a resident could be lying on the floor for up to 2 hours. Residents risked anxiety, despair, pain due to injury, helplessness, and anger if they were unable to call staff for help. CNA P entered Resident #10's bathroom and noticed the call light pull string was knotted and wrapped around a fixed support bar. This investigator pulled the call light pull string and it was inoperable when pulled from the end under the fixed support bar. CNA P untied the knot and the unwrapped string, the call light pull string was tested and it was operable. This investigator, having used a measuring tool from a state issued iPhone 13, the end of the call light pull string was 1 inch from the floor. CNA P entered Resident #41's bathroom and noticed the call light pull string was knotted 4 times. CNA P untied the 4 knots. The call light pull string was tested and it was operable. This investigator, having used a measuring tool from a state issued iPhone 13, the end of the call light pull string was 3 inches from the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 28 of 29 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 02/25/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 2/22/20827 at 1:55 PM of Resident #51's call light pull string in Resident #51's bathroom revealed the 10 knots were undone and the activation of the alarm to alert staff was operable when pulled from the end of the string. This investigator, having used a measuring tool from a state issued iPhone 13, the end of the call light pull string was 3 inches from the floor. Interview on 2/24/24 at 10:35 AM with LVN F revealed the call light pull strings were in the restroom and they were extended to the floor in case a resident needed help from the floor position. Risks for residents not being able to reach and call for assistance were increased skin breakdown, prolonged pain, isolation, anger, helplessness, and loss of trust with staff. If the strings were not in their intended place the failure would lie on proper education, staff awareness, the last staff member to be in the bathroom. Interview on 2/24/2024 at 10:50 AM with ADON B revealed the call light pull strings were utilized for residents to call from help in the bathroom. The strings were long, so they were able to reach it from the floor position. Staff were trained to make sure the string was in its intended position. The failure for the call light pull strings, having not been in their intended position, was staff not recognizing and correcting the string's intended location; and, having made sure the string was accessible to the resident if they were lying on the floor. Interview on 2/25/2024 at 10:15 AM with the ADM revealed there was a facility policy to address the call light system. The ADM expected his staff to have noticed, and corrected, any issue or concerns with the call light strings operational status and location. The ADM conducted a facility wide inspection for the call light pull strings in the resident's bathrooms and stated there were no more irregularities. The ADM felt the incorrect placement and operability issues with the call light pull strings were isolated and each concern was corrected. Record review of the facility's Answering the Call Light Policy, dated September 2003, reflected (1) explain the call light to the new resident; (2) demonstrate the use of the call light; and (3) ask the resident to return the demonstration so that you will be sure that the resident can operate the system. (Explain to the resident that a call system is also located in the bathroom. Demonstrate how it works.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 29 of 29