Health inspection·July 3, 2024

F 0684 following: Level of Harm - Actual harm [MA B] came to let me know that she changed [Resident #1]'s brief and that he has redness, possible sores on his bottom, I said yes, the day nurse told me, she had already placed barrier cream on. Will have wound care nurse f/u, he currently does not have any wound care order. Will continue barrier cream for now. Residents Affected - Some Review of Resident #1's progress notes, dated 07/02/24 and documented by LVN C, reflected the following : Advised wound care nurse of areas to L (butt) cheek. Review of Resident #1's progress notes, dated 07/03/24 and documented by LVN D, reflected the following: Cleaned area on left upper buttocks with NS and applied foam dressing. Review of Resident #1's Weekly Skin Review, dated 07/03/24, reflected the following : Left buttock - round red area, blanches upon touch, measures 11 mm x 10 mm; Left buttock - round red area, blanches upon touch, measures 8 mm x 9 mm; Left buttock - 12 mm x 12 mm open red area Review of Resident #1's physician order, dated 07/03/24, reflected treatment to left upper buttock open area: Clean with NS, pat dry, apply collagenase powder and cover with bordered foam dressing two times a day. During an interview on 07/03/24 at 10:10 AM, Resident #1 stated he had redness/burning to his backside for several days. He stated he had not recently been seen by the wound care nurse. He stated he did not know how often they were supposed to be applying cream/treating his backside but it was obviously not enough since it was still there, burning, and causing him pain. During a telephone interview on 07/03/24 at 2:30 PM, LVN A stated MA B informed her about the red areas to Resident #1's buttocks on 06/30/24. She stated she assessed the areas and they were not too major at that point. She stated she applied barrier cream to the area and documented it on her shift report for the oncoming nurse. She stated she worked on 07/01/24 and noted blanchable areas and one of the red spots had a top layer that was gone and it had started to open. She stated she placed a note on her shift report to have the WCN follow up and write orders for treatment. During a telephone interview on 07/03/24 at 2:46 PM, MA B stated she informed LVN A on 06/30/24 about the redness to Resident #1's buttocks. She stated there were at least three small circles that were red and she felt as though they were infected and needed treatment. She stated she was told by LVN A just to apply barrier cream to the areas. During a telephone interview on 07/03/24 at 2:53 PM, LVN C stated she notified the WCN on 07/02/24 about the red areas to Resident #1's buttocks but did not hear back or receive any orders . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 2 of 5 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 07/03/2024 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 0684 On 07/03/24 multiple attempts were made to contact the WCN. A returned call was not received prior to exiting. Level of Harm - Actual harm Residents Affected - Some During an interview on 07/03/24 at 3:10 PM, the DON stated her expectations was that any skin integrity issues were documented by the nurses either in the residents' progress notes or by completing a skin assessment. She stated they should notify the WCN and get orders that same day, especially if there was an open area or a pressure injury. She stated LVN D informed her early that morning that it looked like an area to Resident #1's buttocks was opening. She stated the WCN has yet to assess him, but LVN D put in standard wound treatment orders until the WCN could assess him. She stated the nurse that initially identified the open area on Resident #1 should have notified the WCN or doctor. She stated it was not acceptable to just leave it in their shift reports and it did not meet her expectations. She stated areas could become infected or could worsen if treatment orders were not implemented right away . Review of the facility's undated Skin Management Policy, reflected the following: . New Skin Condition: The charge nurse will communicate findings to the RP and MD and obtain an order for treatment/dressing changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 3 of 5 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 07/03/2024 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 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (Resident #2) of two residents observed for infection control practices. Residents Affected - Few The facility failed to ensure staff (CNA E and CNA F) followed infection control practices while performing peri care on Resident #1. This failure placed residents at risk for cross contamination and the spread of infection. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including stroke, unspecified dementia, age-related osteoporosis (a condition when bone strength weakens and is susceptible to fracture), multiple fractures, and a history of urinary tract infections. Review of Resident #2's quarterly MDS assessment, dated 04/09/24, reflected a BIMS of 00, indicating a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was independent for toileting hygiene. Section H (Bladder and Bowel) reflected she was always incontinent of bladder and bowel. Review of Resident #2's quarterly care plan, dated 05/19/24, reflected she had an ADL self-care performance deficit related to weakness and debility with an intervention of requiring 1-2 staff members for assistance with toileting. Observation on 07/03/24 at 1:56 PM, revealed CNA E entering Resident #2's room, pulling gloves out of her pocket, and donned them without washing her hands. CNA F entered the room, washed her hands and donned her gloves. CNA E pulled three wipes from the package and layered them, cleaned Resident #2's left groin, flipped the wipes and cleaned the right groin, and threw the wipes in the trash. She then pulled two wipes from the package and wiped the vaginal area from front to back then threw the wipes away. Resident #2 was turned on her right side with assistance from CNA F and CNA E pulled two wipes from the package and wiped the buttocks, folded the wipes and used them again to wipe the buttocks. The dirty brief was removed by CNA E from behind the resident and a new brief was placed under the resident (without hand hygiene or gloves changed). Resident #2 was rolled onto her back and her brief was secured. CNA E covered Resident #1, picked up oxygen tubing and call light to untangle them while still wearing the soiled gloves She attached the call light to the bed and stated she was going to wash her hands. During an interview on 07/03/24 at 3:10 PM, the DON stated her expectations during peri care were that the staff utilize hand sanitizer or soap and water before donning gloves. She stated they should then remove the dirty brief and don a new pair of gloves. She stated a wipe should never be used more than once; you should wipe once and throw it away before getting a new wipe. She stated when going from dirty to clean, gloves should be changed in between. She stated not changing gloves before going from dirty to clean or utilizing the same wipe more than once would cause opportunities to spread infection . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 4 of 5 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 07/03/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 07/03/24 at 3:19 PM, CNA E stated she knew she messed up during peri care with Resident #1. She stated she should not have folded the wipes to reuse them and should have changed gloves in between going from dirty to clean. She stated she knew the policy and procedure said to change gloves from dirty to clean and to utilize hand sanitizer. She stated not changing gloves and reusing wipes while cleaning a resident could lead to infection. Residents Affected - Few Review of a facility in-serviced entitled Peri Care, dated 06/12/24, reflected the aides were reeducated on their Perineal Care Policy. Review of the facility's Perineal Care Policy, revised December 2011, reflected the following: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure: . 2. Wash and dry your hands thoroughly. . Do not reuse the same disposable wipe/washcloth or water to clean the urethra or labia. . 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Put on clean gloves and place new brief and secure in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 5 of 5