Health inspection·December 22, 2025

F 0842 procedure/treatmentE. Whether the resident refused the procedure/treatmentF. Notification of family, physician or other staff, if indicated; andG. The signature and title of the individual documenting. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 2 of 4 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 12/22/2025 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 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 establish and 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 1 of 5 residents (Resident #2) reviewed for infection control practices.The facility failed to ensure Resident #2's soiled wash cloth was removed from the bedside table on 12/22/2025The facility failed to ensure Resident # 2's urinal bottle was emptied on 12/22/2025. This failure placed residents at risk of cross contamination. Findings included:Record review of Resident #2's face sheet dated 12/22/2025 reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had diagnoses which included congestive heart failure(heart can't pump enough oxygen-rich blood to meet the body's need),Type 2 diabetes(body does not make enough insulin)and hypertensive heart disease(heart problems from long term high blood pressure).Record review of Resident #2's care plan dated 12/22/2025, reflected Resident #2 exhibited ADL self-care performance deficit that required assistance with ADL's which included intervention of self-performance extensive support.A record review of Resident #2's Quarterly MDS assessment, dated 10/01/2025, reflected Resident #2 had BIMS score of 15 indicating the resident was cognitively intact. Observation on 12/22/2025 at 9:34 AM., revealed Resident #2's soiled wash cloth was sitting on the bedside table.Observation on 12/22/2025 at 9:34 AM., revealed Resident #2's urinal bottle sitting on bedside table filled to the top of the urinal bottle.During an interview with Resident #2 on 12/22/2025 at 9:35 AM he stated that he used the call light around 6:30 AM this morning and CNA B came in and stated she would be back. Resident # 2 stated that CNA B had not come back, and the soiled washcloth that he used to clean himself with needed to be removed from the bedside table. Resident # 2 stated that he had placed the soiled washcloth on the bedside table so CNA B could take it to the laundry room to be washed. Resident # 2 stated that the urinal was full and needed to be emptied. Resident # 2 stated that he had placed his urinal on the bedside table so it could be emptied by CNA B.During an interview with CNA B on 12/22/2025 at 3:17 PM stated that she was Resident # 2's CNA and she was responsible for removing the soiled washcloth from the bedside table. CNA B stated she answered the call light around 6:30 AM and told Resident # 2 that she would be back. CNA B stated she did not return right then, and she could not recall the time she returned to assist Resident #2. CNA B stated that she was assisting other residents call lights and she totally forgot to return to Resident # 2 to remove the soiled washcloth from the bedside table. CNA B stated it was expected for her to remove Resident # 2's soiled wash cloth he used to clean himself for infection control. CNA B stated that she was assisting other residents call lights and she totally forgot to return to Resident # 2 to empty the urinal. CNA B stated it was expected for her to empty Resident # 2's urinal to prevent from spilling.During an interview with the DON on 12/22/2025 at 4:35 PM, the DON stated it was expected for CNA B to remove the soiled washcloth after each use for infection control purposes. The DON stated it was expected for CNA B to empty Resident #2's urinal. The DON stated rounds were made every two hours and any staff can empty a urinal. The DON stated with the urinal filled it could be knocked off the bedside table and may cause a slip and fall.During an interview with the ADM on 12/22/2025 at 5:19 PM, the ADM stated it was expected for CNA B to have removed the soiled washcloth on the bedside table. It was expected for CNA B to bag the soiled washcloth to be sent to laundry to be washed. the ADM stated it was expected for CNA B to empty Resident # 2's urinal. The ADM stated that a slip and fall could have occurred if the urinal had been knocked over and spilled over on the floor. The ADM stated any staff can empty a urinal when it is full.Review of the facility policy Policies and Practices Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 3 of 4 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 12/22/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Infection Control revised 07/2014 reflected This Facility Infection Control policies and practices are intended to facilitate maintaining a safe, sanitary a safe, sanitary and comfortable environment and to help percent and manager transmission of diseases and infections. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676213 If continuation sheet Page 4 of 4