Health inspection·May 14, 2024

F 0695 ensure the BiPAP Machine was at the correct settings, per order. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's Order Summary Report, dated 5/9/2024, indicated an order, made 12/23/2023, to change BiPAP tubing every 3 months. Residents Affected - Few Record review of Resident #1's vital signs in PCC at the facility, dated 3/4/2024, indicated Resident #1's O2 saturations (the amount of oxygen in her blood) was 82%. Record review of Resident #1's hospital records indicated Resident #1 admitted to the hospital, on 3/4/2024 to 3/14/2024, for Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Resident was admitted to the ICU and was intubated (a tube placed through the resident's airway to breathe.) She was extubated (removal of the tube placed in resident's airway) on 3/5/2024 and discharged to a regular hospital bed on 3/6/2024. The resident received her BiPAP machine, from the nursing facility, and the machine had performed well. Resident was diagnosed with pneumonia (which was an infection in the lungs caused by bacteria, viruses, or fungi) on 3/7/2024. The hospital summary stated the resident's responsible parties [alleged the nursing facility had not been successful in the correct placement of the resident's BiPAP mask.] Record review of Resident #1's Order Summary indicated an order, revised on 3/18/2024 to start 3/24/2024, to clean BiPAP mask, tubing, filter, and water canister weekly every night shift on Sunday. An order, revised on 3/18/2024 to start on 3/24/2024, indicated the residents BiPAP machine settings were supposed to be 15 IPAP and 4 EPAP. (These setting controlled positive airway pressure for inhaling and exhaling, respectfully.) Record review of Resident #1's treatment record, March 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 3/24/2024 (documented complete by LVN A.) Record review of Resident #1's hospital records indicated Resident #1 admitted to the hospital, on 3/27/2024 to 3/30/2024, for Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Resident expressed SOB. Her O2 saturations (the amount of oxygen in her blood) was 89 %. Resident was intubated on 3/27/2024 in the emergency room. Record review of Resident #1's treatment record, March 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 3/31/2024 (documented by LVN E). Record review of Resident #1's hospital records indicated Resident #1 admitted to the hospital, on 4/6/2024 to 4/16/2024, for Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Resident expressed SOB. Her O2 saturations were 78 % on the way to the hospital. Having arrived, her O2 saturations were 49%. She was noted to be cyanotic (blue or purplish skin due to deficient levels of oxygen in the blood) at the face, lips, and ears. Resident was intubated for concern for severe hypercapnia (elevated carbon dioxide.) The hospital summary indicated the resident had active bilateral pneumonia. Record review of Resident #1's treatment record, April 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 4/7/2024 (documented by LVN A,) 4/14/2024 (documented by LVN E,) 4/21/2024 (documented by LVN F,) and 4/28/2024 (documented by LVN G.) Record review of Resident #1's treatment record, May 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 5/5/2024 (documented by LVN E.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 2 of 9 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 05/14/2024 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview and observations on 5/9/2024 at 9:30 AM with Resident #1 revealed her in bed, the back of the bed was elevated at a 45-degree angle, and she had continuous oxygen via nasal canula (oxygen delivery through a tube inserted in each nostril.) Resident # 1 stated she had been to the hospital 3 times in the last 3 months due to respiratory distress. She stated the reason for the hospitalizations was due to inconsistent use of her BiPAP mask; and that staff had not made sure she was wearing it like she should. She went to the hospital on 3/4/2024 due to low oxygen levels, while there, an RP brought her BiPAP machine from the nursing facility to the hospital. The hospital staff changed the settings and utilized the resident utilized the BiPAP machine while there. She stated she had to go to the hospital two more times due to similar instances of respiratory distress. She denied having seen nursing staff clean her BiPAP Machine or change the filter. She did not know how to check the settings on the machine, and she was not sure who to ask to make sure the settings were correct. The filter for her BiPAP Machine, which was a small rectangular mesh cloth, was designed to fit in a small rectangular compartment on the back side of the machine. The filter was designed to clean room air going into the machine used to produce the proper air pressure flow. The filter was black with discoloration. The settings on the BIPAP were 16 IPAP (Inhale) and 8 EPAP (Exhale.) She did not have any filters, masks, or tubing in her room or in her possession. Phone interview on 5/9/2024 at 11:00 AM with the facility's MD revealed Resident #1 had been to the hospital on 3 separate occasions since 3/4/2024. Her diagnoses were Pneumonia, Congestive Heart Failure (which was a long-term condition that happened when the heart could not pump blood well enough to give your body a normal supply,) and Chronic Obstructive Pulmonary Disease (COPD, which was a respiratory condition characterized by persistent breathlessness and cough.). The MD stated dirty BiPAP filters were most likely not the sole reason that was causing Resident #1's exacerbated shortness of breath and respiratory distress, but more than likely a contributor. Interview on 5/9/2024 at 12:10 PM with MSMR revealed that any replacement materials for Resident #1's BiPAP machine would come from the local BiPAP/CPAP machine company. She stated she did not have any masks, tubing, or filters on hand. She stated she had not ordered any filters. The company did come to the facility to size Resident #1 for the right mask size, but the topic of filters never came up. The facility did not have any supplies for Resident #1's BiPAP Machine on hand. Interview and observation on 5/9/2024 at 12:35 PM with the ADON in Resident #1's room revealed the BiPAP Machine filter was very dirty and did not appear to have been changed weekly. The IPAP 16 (Inhale) and EPAP 8 (Exhale) were not congruent with the orders listed in PCC. The ADON stated the orders to clean BiPAP mask, tubing, filter, and water canister weekly every night shift on Sunday were located on the treatment record but was unable to verbalize the location of the replacement filters. The ADON stated the new filters should have been requested through MSMR in medical supply. 2. Record reviews of Resident #2's Quarterly MDS, dated [DATE] indicated the resident was a [AGE] year-old female that admitted to the facility on [DATE]. She was diagnosed with Chronic Obstructive Pulmonary Disease (COPD) (which was a respiratory condition characterized by persistent breathlessness and cough,) and Obstructive Sleep Apnea (which was a medical condition marked by throat muscles having relaxed and having blocked the person's airway.) Section C., Cognitive Patterns: Resident #2 had a BIMS Score of 14. A BIMS Score of 14 indicated the resident did not have cognitive impairment. Resident #2 was not coded as wearing a CPAP. Record review of Resident #2's CP reflected a [Focus] area, revised 12/14/2023, evidenced by having (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 3 of 9 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 05/14/2024 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few been at risk for ineffective airway clearance D/T COPD and Sleep Apnea. The [Goal,] revised on 12/12/2023, indicated the resident would display normal breathing. An intervention for nursing staff, initiated on 12/14/2023, indicated staff was supposed to maintain CPAP per orders. Record review of Resident #2's May 2024 treatment record, under the heading of [Schedule for May 2024,] Resident #2 was ordered to have her mask cleaned, tubing cleaned, filter cleaned, and water chamber weekly. The start date of the scheduled treatment began on 12/17/2023. Record review or Resident #2's treatment record, dated March 2024, indicated her CPAP mask, tubing, filter, and water chamber was cleaned on 3/3/2024 (documented by LVN H,) 3/10/2024 (documented by LVN I,) 3/17/2024 (documented by LVN H,) 3/24/2024 (documented by LVN I,) and 3/31/2024 (documented by LVN H.) Record review or Resident #2's treatment record, dated April 2024, indicated her CPAP mask, tubing, filter, and water chamber was cleaned on 4/7/2024 (documented by LVN I,) 4/14/2024 (documented by LVN J,) 4/21/2024 (documented by LVN I,) and 4/28/2024 (documented by LVN H.) Record review or Resident #2's treatment record, dated May 2024, indicated her CPAP mask, tubing, filter, and water chamber was cleaned on 5/5/2024 (documented by LVN I.) Interview and observation on 5/9/2024 at 3:34 PM with Resident #2 revealed her lying in her bed watching television. She stated she utilized a CPAP machine daily and pointed to it on a table next to her bed. The filter for her CPAP Machine, which was supposed to be a small rectangular mesh cloth, was designed to fit in a small rectangular compartment on the back side of the machine. The filter was designed to clean room air going into the machine used to produce the proper positive airway pressure flow. When the compartment was opened, there was not a filter in the required location. Resident #2 stated she had not observed staff having cleaned her CPAP machine or having changed the filter weekly. Resident #2 denied any exacerbation of her COPD or problems with the sleep apnea. Record review of the facility's BIPAP/CPAP policy, dated April 2010, indicated BiPAP/CPAP were used to provide the spontaneously breathing resident with continuous positive airway pressure, with or without supplemented oxygen. To improve arterial oxidization in residents with respiratory insufficiencies, obstructive sleep apneas, and restrictive/obstructive lung diseases. The purpose is to promote resident comfort and safety. Review the physician's order to determine the oxygen concentration and flow, and the pressure, such as CPAP, IPAP, and EPAP. The policy indicated filters were required for BIPAP/CPAP supply. Record review on 5/20/2024 of URL: Sleepfoundation.org; BiPAP/ CPAP machines were both forms of positive airway pressure therapy, which used compressed air to open and support the upper airway during sleep. A portable machine generated the pressurized air and directed it to the user's airway via a hose and mask system. Both systems used similar masks, hoses, and other accessories. The machines were humid and often warm, having made them the perfect home for mold, bacteria, viruses, and other harmful microbes. Having cleaned your machine components regularly washed these microbes away and prevented them from reaching dangerous levels, but having neglected your machine's hygiene could have led to both acute and chronic respiratory illnesses. Record review on 5/20/2024 of URL: National Library of Medicine, Pulse Oximetry-Stat Pearls (on-line school for physicians) - NCBI Bookshelf (nih.gov), the normal oxygen levels displayed on a pulse oximeter (a tool to measure the oxygen in the blood) were commonly supposed to range from 95% to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 4 of 9 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 (X3) DATE SURVEY COMPLETED A. Building 05/14/2024 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 100%. Oxygen saturation was an essential element of patient care. Oxygen was tightly regulated within the body because hypoxemia (low levels of oxygen) could have led to many acute adverse effects on individual organ systems. These included the brain, heart, and kidneys. Interview on 5/9/2024 at 6:01 PM with the ADM revealed that Resident #1 and Resident #2 had not been receiving respiratory care per physician orders. Neither Resident #1, nor Resident #2, had been receiving BiPAP or CPAP care per physician orders. The facility did not possess replacement filters for either CPAP or BiPAP equipment, but the nursing staff was checking off treatments on the nurse's treatment record for Resident #1 and Resident #2, having indicated they had been changed/cleaned. Resident #1 had been hospitalized on [DATE] for respiratory distress, 3/27/2024 for respiratory distress, and 4/6/2024 for respiratory distress. All of which, a contributing factor could have been the result of dirty respiratory care equipment. It was determined that criteria had been met to initiate an IJ. The IJ was called and the administer was presented with the IJ template at 6:01 PM. The following POR by the facility was accepted on 5/10/2024 at 1:14 PM. The notification of IJ states as follows: Statement of deficient practice: F695: The facility failed to ensure its BiPAP/CPAP users received respiratory care in accordance with highest professional standards which placed Resident #1 at risk of exacerbation of her SOB, having resulted in Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Impact Statement: On 5/09/24 an abbreviated survey was initiated on 5/09/24 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to a significant medication error. 1. How were other residents at risk affected by this deficient practice identified? The facility Administrator, DON/Designee completed an audit of all Residents with BiPAP/CPAP orders ordered in the last 30 days to ensure the residents have not had an adverse effect from their normal baseline 5/09/24. Residents with BiPAP/CPAP orders have the potential to be affected by this deficient practice, 2 of the residents who were identified as having BiPAP/CPAP orders were not affected. 2. What corrective actions have been implemented for the identified resident? Resident #1's BiPAP settings were adjusted by the BiPAP/CPAP company technician, to meet physician orders, BiPAP machine filter was cleaned by facility ADON, along with the tubing. Resident #1 is currently in the facility and stable condition as of 5/9/24. On 5/9/24, replacement filters were obtained from facility DME company by central supply clerk, who will also monitor inventory of filters weekly to ensure facility has adequate stock. Regional [NAME] President in-serviced Administrator and DON/Designee on the identification of new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 5 of 9 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 05/14/2024 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 0695 Level of Harm - Immediate jeopardy to resident health or safety BiPAP orders and verification of settings, as well as the proper cleaning methods and frequency of cleaning of BiPAP equipment on 5/9/24. On 5/9/24, Administrator, DON/Designee in-serviced the licensed nursing staff on the identification of new BiPAP orders and verification of settings, as well as the proper cleaning methods and frequency of cleaning of BiPAP equipment. Residents Affected - Few What corrective actions were taken? 3. The following actions were initiated immediately on 5/09/2024. a. Nursing management was educated on 5/09/2024 by the Administrator, on identifying and reviewing all new orders for BiPAP/CPAP machines, during daily clinical meeting, to ensure BiPAP orders are followed per physician orders. b. Initiated in-services on 5/09/24 with licensed nurses, by Administrator, on proper cleaning methods of BiPAP equipment (masks, hoses, filters) and frequency of weekly filter changes, both to be completed by licensed nurses. c. Newly hired licensed nurses will be in serviced during the onboarding process by DON on identifying and reviewing all new orders to ensure BiPAP settings are being followed and set appropriately on BiPAP equipment. d. PRN and Agency nurses will be in-serviced by DON/Designee, prior to working designated shifts, on identifying and reviewing all new orders to ensure BiPAP settings are being followed and filters are being cleaned weekly. 4. How will the system be monitored to ensure compliance? a. DON/Designee Will review the Order List Report for newly received orders and compare it to resident new BiPAP orders daily for 4 weeks. If discrepancies are identified, we will notify the physician immediately for clarification, Quality Assurance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 6 of 9 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 05/14/2024 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 0695 Level of Harm - Immediate jeopardy to resident health or safety An impromptu Quality Assurance and Performance Improvement review (quick meeting) of the plan of removal was completed on 5/09/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal. This plan will be monitored monthly during Quality Assurance and Performance Improvement meetings ongoing for any further education identified. Residents Affected - Few Monitoring began 5/10/2024 at 1:14 PM. Interview on 5/10/2024 at 1:50 PM with LVN B revealed nursing staff was made aware of BiPAP/CPAP orders when new residents come to the facility with their orders, or they have had a sleep study while a resident. New orders were under the orders tab in PCC. Settings were found on the machine and staff needed to confirm they match the orders. Tubing and masks get cleaned every week by taking the masks apart and rinsing it. Tubing and masks get cleaned one time a week: the filter and water container 1 x week. The facility has the equipment they needed to maintain the machines. LVN B attended an in-service on 5/10/2024 given by the ADON. Interview on 5/10/2024 at 2:05 PM with LVN C revealed the nursing staff was made aware of new BiPAP/CPAP orders through PCC or paper orders. New orders in PCC would be highlighted in red. The machine had buttons for setting and those settings were supposed to match those on the orders. Nursing staff checked orders for treatments each week. Nursing staff cleaned the mask with soap and water each week and let air dry. Cleaning consisted of having disconnected the tubing from them machine and having washed it with warm soapy water weekly. The filter was rinsed and placed between two paper towels to dry. Wet filters did not go back into the machine, which would be bad. LVN C attended an in-service today, 5/10/2024 for BiPAP/CPAP care by the ADON. Day shift started cleaning the BiPAP/CPAP during the day on Tuesday. Interview on 5/10/2024 at 2:15PM with LVN D revealed nursing staff was made aware of BiPAP/CPAP orders when a resident arrived from the hospital, admitted , if ordered by the medical director, or ordered by the nurse practitioner. New orders were found in PCC; PCC to be checked daily for new orders. The settings for the BiPAP/CPAP machine were found on the machine and the settings needed to match what was in the orders. Masks were supposed to be cleaned each week with soap and water. The tubing was supposed to be rest with water each week and the filter was rinsed with water each week. The mask and the tubing were supposed to be exchanged once a month. LVN D attended an in-service earlier this week on BiPAP/CPAP care. The DON provided the training. Interview on 5/10/2024 at 2:25 PM with the RN revealed new BiPAP/CPAP orders would show up on the administration record, under new orders, or pop up under the To Do List. The settings on the BiPAP/CPAP were accessible from the machine itself. Those numbers had to match what was on the orders. Every week, nursing staff was supposed to clean the mask, the tubing, and the filter. All items needed to be air dried. The RN stated she attended an in-service today, 5/10/2024, presented by the ADON. Interview on 5/10/2024 at 2:40 PM with the ADON revealed all new BiPAP/CPAP orders were supposed to be listed on the 24-hour report, which was a report having pertained residents' medical changes. New BiPAP/CPAP users also could have had orders when they returned from the hospital or having had seen the doctor. Those new orders were listed in PCC. New orders needed confirmation, so they needed follow up. BiPAP/CPAP settings were found on the machine. New admissions were asked for paperwork regarding their BiPAP/CPAP settings. The settings on the machine needed to match those on the orders. The hoses, the mask, in the filters needed to be cleaned with soap and water weekly; and air dried as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 7 of 9 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 05/14/2024 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few much as possible. The ADON was briefed on the BiPAP/CPAP policies by the DON; The ADON in-serviced the staff. Interview on 5/10/2024 at 2:55 PM with the DON revealed new BiPAP/CPAP orders were found on the 24-hour report, put into PCC, and flagged for confirmation and items needed to be completed while on shift. The machine settings were found on the machine itself, and those settings needed to match those that were in the order. Once a week, she cleaned the mask with soap and water. The filters were rinsed with water weekly also and patted dry before having placed them back in the machine. The DON attended an in-service for BiPAP/CPAP yesterday, 5/9/2024, by the RVP. Interview and observation on 5/10/2024 at 5:05 PM with the MRMS revealed he monitored the respiratory supplies daily and weekly. The O2 company came to the facility and serviced the machines once a month. The MRMS displayed the supply of BiPAP/CPAP hoses and various other tubing for respiratory equipment. She stated the BiPAP/CPAP filters were delivered on 5/9/2024. Record review of BiPAP/CPAP in-service, performed by the ADM to the ADONs on 5/9/2024, for BiPAP/CPAP: Identify and review all new BiPAP/CPAP orders. Record review of BiPAP/CPAP in-service performed by the ADM and the ADON to the Licensed Nursing Staff, performed on 5/9/2024, for BiPAP/CPAP: Identify and review all new orders. Cleaning. Replacement supplies. Record review of BiPAP/CPAP invoice, dated 5/9/2024 and 5/10/2024, delivering BiPAP/CPAP tubing and filters. Record review of BiPAP/CPAP in-service performed by the RVP to the ADM and DON, dated 5/9/2024. New orders, settings, cleaning, and filter replacement. Record review of ADON confirmation of cleaning Resident #1's machine, dated 5/9/2024. Record review of ADON confirmation of audit for BiPAP/CPAP filters, dated 5/14/2024. Record review of DON plans, undated, for new hires, shift workers, and PRN staff. Record review of the QAPI Team members email review, dated 5/92024, having discussed the F695 POR. Interview and observation on 5/10/2024 at 5:10 PM with Resident #1 revealed she was in bed, clean, and in no distress. The BiPAP machine was a new device; hose and mask were clean placed in a plastic bag. Resident voiced no complaints and stated she was pleased with having clean equipment now. The ADM was informed the Immediate Jeopardy was removed on 5/10/2024 at 5:30 PM. The facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a severity level of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Interview and record review on 5/13/2024 at 4:20 PM with LVN A revealed she had signed off treatment for Resident #1's BiPAP on 3/24/2024 and 4/7/2024. She stated the order to clean the machine, and change the filter out weekly, were on the nurse's treatment record. She recalled checking off the treatments and recalled not having clean filters to exchange. She stated she had informed the ADON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 8 of 9 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 05/14/2024 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 0695 There were no filters on hand to change out the old. Level of Harm - Immediate jeopardy to resident health or safety Interview and observation on 5/14/2024 at 11:15 AM with Resident #2 revealed she had a new CPAP machine, and the machine had a clean filter in place. She was getting used to the new mask. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 5/14/2024 at 2:25 PM with the DON revealed cleaning masks, tubing, and changing filters were important to keep BiPAP/CPAP therapy equipment clean. Clean equipment reduced the risk of infection and kept the air flow optimum. The facility had a policy covering the BIPAP/CPAP therapy and the nursing staff was not following the facility policy. The residents who were using BiPAP/CPAP treatments were placed at risk for portals for infection. Event ID: Facility ID: 676213 If continuation sheet Page 9 of 9