F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to submit a completed and accurate request for
nursing facility specialized services in the LTC Online Portal within 20 business days from the IDT for 1 of 1
(Resident #1) resident reviewed for delinquent PASARR processes.
The facility failed to ensure Resident #1 received the services recommended by the PASARR evaluation
when they failed to submit a complete and accurate request for NFSS in the LTC online Portal within 20
business days from the IDT meeting. This failure caused a delay in her Medicaid Entitled Services including
physical therapy and occupational therapy.
This failure placed Resident #1 at risk of not achieving or maintaining her highest practicable level of
physical functioning and could potentially result in increased disability.
Findings include:
Review of Resident #1's undated face sheet reflected that she was a [AGE] year-old female admitted
[DATE] with diagnoses of Mild Intellectual Disabilities, Diabetes Type 2, Hypertension (high blood pressure),
chronic kidney disease, stage 5, and Cerebral Infarction (stroke).
Review of Resident #1's 6/5/25 Quarterly MDS reflected her BIMS score was 15 which indicated she was
cognitively intact.
Review of resident #1's 5/5/25 Care Plan reflected a care area initiated 1/23/25 for falls related to poor
balance, unrealistic sense of physical abilities with a goal to resume usual activities and interventions
including physical therapy.
Observation on 6/23/25 at 10:56 AM of Resident #1 revealed her using a manual wheelchair for mobility in
the activities/bingo room.
Interview attempted on 6/23/25 at 11:14 AM with Resident #1 but she had left the facility for dialysis and
was unavailable.
In an interview on 6/23/25 at 2:25 PM the MDS-RN stated, the IDT meeting for Resident #1 was held on
4/10/25. She stated that following the meeting NFSS forms were submitted on 4/24/25, 5/7/25, and 5/8/25
for physical and occupational therapy recommendations. She further stated all the forms were rejected with
errors and the final form on 5/8/25 was marked as late according to PASARR timelines.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676213
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
06/23/2025
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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In a 2nd interview on 6/23/25 at 3:49 PM the MDS-RN stated, PASARR was important because it provided
residents who had intellectual and mental disabilities extra services to help them cope with their disabilities.
She stated that she had recently assumed responsibility for the PASARR process and that if PASARR was
not done, residents may miss extra therapy and lose strength or independence.
In an interview on 6/23/25 at 4:15 PM the DT stated, if PASARR recommended services it was important to
do them to maintain a resident's strength, balance, and safety. She stated the MDS-RN was responsible for
handling the PASARR processes and that failure to follow the PASARR recommendations could lead to a
decline in the resident's function.
In an interview on 6/23/25 at 4:27 PM the DON stated, PASARR was important because it allowed
residents to get additional services that they needed. She stated, the MDS-RN was responsible for doing
PASARR and that if PASARR was not done then residents could miss services and not get as strong as
they could. She stated that she and the MDS-RN were immediately setting up a new meeting for Resident
#1.
In an interview on 6/23/25 at 4:40 PM the ADM stated, PASARR was important to provide residents
specialized services to meet their needs. He stated the MDS-RN was responsible for handling PASARR
and that the negative outcome to residents if PASARR was not done was that the resident would not
improve in areas they could have improved in.
Record Review of Resident #1's undated NFSS form reflected:
Submission date of 5/7/25.
Physical Therapy and Occupational Therapy were requested.
Denial date on 5/20/25 for incorrectly completed signature page.
Record Review of the facility policy titled, PASRR Clinical Policy and dated May 2014, reflected:
The MDS-RN will coordinate and deliver specialized services the facility was responsible for providing.
The MDS-RN /DON will initiate delivery of specialized services.
The MDS-RN/DON will monitor the LTC portal.
The policy did not include a timeline from the IDT meeting.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676213
If continuation sheet
Page 2 of 2
