Health inspection·January 10, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm competencies including resident rights. She stated on hire and annually CNA's were trained and checked off on competencies. She stated she had only been in the position for 2 months and had not done one on one reviews the CNA's but each of them had been previously trained. She stated before starting any care the CNA should close the door and the privacy curtain to prevent embarrassment if someone were to walk in the room to them exposed. Residents Affected - Few During an interview on 01/10/24 at 3:05 pm, the DON stated that on hire and annually staff were trained to pull the curtain for resident care for privacy and dignity. She stated all staff were responsible for ensuring resident privacy and if a resident were exposed it could cause dignity issues like shame and embarrassment. During an interview on 01/10/24 at 3:21 pm, the administrator stated everyone was responsible for ensuring resident privacy and dignity and expected that the facility policy was followed in order to prevent a negative outcome to a resident like embarrassment. Record review of facility's policy titled Quality of Life - Dignity dated October 4, 2022 indicated, 10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 2 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to immediately inform the resident's responsible party when there was an accident involving the resident which resulted in injury or had the potential for requiring physician intervention for 1 of 5 residents (Resident #18) reviewed for notification of change of condition. The facility failed to notify Resident #18's responsible party when Resident #18 sustained an unwitnessed fall on 12/29/2023 on or about 3:30 AM in her room when she slid out of bed to the floor. This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being. Findings included: Record review of an admission Record for Resident #18 dated 1/9/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of senile degeneration of brain (mental deterioration or loss of thinking ability with old age), psychotic disorder (disconnect from reality that causes strange behaviors), and PVD (narrowing of the blood vessels in the legs). Record review of a care plan for Resident #18 dated 11/16/2023 indicated she had electronic monitoring/camera in her room, and it was managed by family. Record review of a care plan for Resident #18 dated 12/15/2023 indicated she was a high risk for falls related to confusion, deconditioning, poor communication/comprehension with interventions to educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Record review of a bed rail consent form for Resident #18 dated 11/10/2023 was signed by family consenting to have bed rails and understanding the risks. Record review of an admission MDS assessment dated [DATE] for Resident #18 indicated she had a BIMS of 00 which indicated severe impairment in thinking and required substantial/maximal assistance with ADL's. Record review of a progress note for Resident #18 dated 12/29/2023 by DON indicated, .met with the RP of Resident #18 who reported that Resident #18 had a fall during the night and that the RP was not informed. No documentation reporting a fall noted. Resident #18 has a camera in room which RP has access to on her phone. RP showed video of what appeared to be resident slipping from bed to floor in room. DON assured RP an investigation would take place and she would be updated . During an observation and interview on 1/8/2023 beginning at 3:18 PM, the RP of Resident #18 said Resident #18 has had a total of 3 falls since admission to the facility in November 2023 and was on hospice services. RP indicated they have a camera in the room of Resident #18 and on the morning of 12/29/2023 at about 3:30 AM, Resident #18 slid out of bed to the floor. RP said the video showed staff come in to check on Resident #18 at 5:45 AM and staff found her on the floor and placed her back in bed. RP said later on 12/29/2023 Resident #18 had another fall at about 11:30 AM at the nurse station and sustained a bruise to the right side of her forehead from the fall. RP said the camera did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 3 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not have a history to go back and review footage in the past. RP said she had some still images and recorded video footage on her personal phone from the fall but it did not indicate a time and date of the fall. RP said the family was not informed of the fall until she had the second fall on 12/29/2023 when Resident #18 was sitting at the nurse desk in her wheelchair and tried to get up and fell. RP said the facility staff contacted the family about the second fall and the RP informed them of the fall in the early morning hours that same day. RP said the DON apologized to the family about the first fall on 12/29/2023 and said they were not aware that Resident #18 had a fall that morning during the night shift. During an interview on 1/8/2023 at 10:55 AM, the Administrator said Resident #18 had a fall on 12/29/2023 in the early hours before the 10pm-6 am shift ended. She said Resident #18's RP informed the facility on 12/29/2023 after the facility had called to notify of another fall with Resident #18 about observing the fall on video camera that was in Resident #18's room. She said CNA J was working that night and had only been employed at the facility for about two days and did not notify the charge nurse that Resident #18 had a fall during the shift. She said they contacted CNA J with phone calls and text messages with no response and she self-terminated herself and did not come back to work. During an interview on 1/9/2023 at 2:35 PM, LVN F said she had been employed at the facility since August 2023 and worked the 6 am-2 pm shift on halls 400, 500, and 600. She said Resident #18 had a fall on 12/29/2023 in the early morning hours before her shift started and had another fall later that morning during her shift when Resident #18 was sitting in a wheelchair at the nurse desk. She said Resident #18 threw herself from the wheelchair when she was sitting at the nurse desk. She said she had immediately assessed her and took her vital signs and checked for any injuries and started neuro checks during her shift. She said she contacted the RP, continued to monitor Resident #18, and documented no skin issues or delayed injuries. She said she was not aware that Resident #18 had a fall on 12/29/2023 before her shift started. Attempted a phone interview on 1/10/2023 at 7:55 AM with CNA J with no answer, phone rang multiple times and was unable to leave a voicemail message for a return phone call. Record review of a personnel file for CNA J indicated she was hired at the facility on 12/27/2023. A Notice of disciplinary action dated 12/29/2023 indicated she was suspended without pay for 3 days effective 12/29/2023 for failure to follow policy related to resident falls, failed to notify nurse of fall. No assessment completed prior to moving resident. During an interview on 1/10/2024 at 10:23 AM, RN H said she had worked at the facility for a month on the 10pm-6am shift and worked on the morning of 12/29/2023 with Resident #18. She said she did not know about Resident #18 having a fall on 12/29/2023 until after her shift had ended. She said the facility called her after her shift ended on 12/29/2023 and asked her about a fall with Resident #18. She said on the night shift of 12/28/2023 and morning of 12/29/2023 during her shift, she was working on the hall with Resident #18 along with two other nurse aides and one of the nurse aides was on the hall with Resident #18 but had not worked with her before that night. She said during the night she checked on Resident #18 every 2 hours. She said administered some medication to Resident #18 around midnight and at that time Resident #18 was lying in bed, bed side rail was up, speaking Spanish and kissing the back of her hand saying gracias. She said on the night of 12/29/2023 the aide (CNA J) that was assigned on that side of the hall with Resident #18 had never worked with her before until that night. She said when her shift ended that next morning the aide (CNA J) assigned to the hall of Resident #18 never said anything about Resident #18 having a fall. She said on the morning of 12/29/2023 someone from the facility texted her asking questions about Resident #18 having a fall. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 4 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said she had to go to the facility and write out a witness statement. She said when she rounded on the residents at night, she would enter the room, would not turn on the light, but would use the light on her phone to check to make sure the bed was in a low position and that the resident was still breathing. She said she knew the family had a camera in the room. She said if a resident had a fall, she would assess them and check their vital signs, assess for injuries, notify the family, physician, DON, hospice, and any other people that needed to be notified. During an interview on 1/10/2024 at 3:15 PM, the DON said when a resident had a fall, charge nurses were supposed to depending on the severity of the injury notify the Administrator, ADON, DON, and family. She said she was not aware that Resident #18 had a fall out of her bed on 12/29/2023 until after the RP was contacted about another fall that occurred on the same day and the RP said they reviewed video footage and Resident #18 had a fall in the early hours on 12/29/2023. She said going forward staff would be in-serviced about falls, protocols, conducting neuro assessments and notifications. She said residents could be at risk for serious injury if staff did not know about incidents or report them. She said following the incident on 12/29/2023, she called CNA J who worked on the morning of 12/29/2023 with Resident #18 and she sent a text message and called with no return call or message and CNA J was self-terminated. During an interview on 1/10/2024 at 3:20 PM, the Administrator said family were to be notified any time a change in condition occurred. She said going forward the clinical team would review the incident/accident reports and follow-up to ensure things had been done and responsible parties were notified. Record review of a facility policy titled Change in a Resident's Condition or Status with a revised date of May 2017 indicated, .Our facility shall promptly notify the resident, his or her Attending Physician or Nurse Practitioner and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care). 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 5 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 6 residents (Resident #57) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body) and quality of care. The facility failed to ensure Residents #57's indwelling catheter (drains urine from your bladder into a bag outside your body) was secure and stabilized on 01/09/2023. This failure could place residents at risk for urinary tract infections and catheter related injuries. Findings: Record review of facility face sheet dated 01/10/2024 revealed Resident #57 was a [AGE] year-old male that admitted on [DATE] with diagnosis of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), carcinoma of buccal mucosa( a type of oral cancer that develops in the squamous cells that line the lips and the mouth), neuromuscular dysfunction of bladder (a bladder malfunction caused by an injury of the brain, spinal cord or nerves) and benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of the prostate gland) . Record review of annual MDS assessment dated [DATE] revealed Resident #57 had a BIMS score of 10 moderately impaired cognition. Indwelling catheter present at time of assessment. Record review of comprehensive care plan dated 09/18/2023 revealed Resident #57 had an indwelling catheter at time care plan was updated with a goal that the resident will be/remain free from catheter related trauma. Record review of the physician order dated 12/13/2023 revealed Resident #57 may have an indwelling catheter and to record output every shift. There was an order to ensure privacy bag intact and secure. Record review of a nurse medication administration record dated January 2024 indicated an order for Urinary catheter ensure privacy bag intact and secure. Record review of provider progress note dated 08/01/2022 revealed Resident # 57 had a history of chronic Foley catheter use. During an observation on 01/09/24 at 9:54 AM, Resident #57 had an indwelling catheter present, hanging off the side of the bed suspended above the floor. The bed was in the high position and the foley bag was not secured. During an observation on 01/09/2024 at 10:00 AM, LVN A entered Resident #57 room and placed catheter in privacy bag and secured it to resident's bedframe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 6 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 During an interview on 01/10/2024 at 1:15 PM, LVN A stated that when she entered Resident #57 room on 01/09/2024 she noted that the foley bag was hanging off the side of the bed and not secured. She stated that Resident #57 had returned from radiation treatment and that the emergency medical transport had transferred resident to his bed and did not make sure that his foley catheter was secured to his bedframe. LVN A stated that she was not sure how long Resident #57 had been back in his room or how long the foley catheter bag had been hanging from Resident #57 and not secured. LVN A stated that when emergency transport brings a resident back to the facility, staff must sign paperwork to acknowledge that the resident was back. LVN A stated that she was down the hall and that the nurse from the other hall signed the paperwork when resident #57 returned and that she was not aware that he had returned until she walked past his room. LVN A stated that not securing the foley catheter could lead to infections, the catheter coming out and or trauma to the resident. She stated that it would be uncomfortable for the resident. During an interview on 01/10/2024 at 1:25 PM, CNA B stated when she performed her rounds to check on Resident #57 she checked his foley catheter to make sure the bag was not full of urine and secure. CNA B stated that Resident #57 requested that the foley bag be emptied frequently because the weight of the bag was uncomfortable to him. CNA B stated that residents could get an infection or injury if the foley catheter was not secure. During an interview on 1/10/24 at 3:00 PM, the DON stated the charge nurses were responsible for assessing residents with indwelling catheters to ensure there was a securement device in place or in the case of Resident #57, who refuses a securement device it was secured to the bed. She stated that there were orders for the charge nurses to check that foley catheters are secured each shift. She stated she expected Resident 57's catheter bag be secured and not free hanging. She stated that the charge nurse will check that every time Resident #57 was transferred that his foley bag was secured. During an interview on 01/10/24 at 3:30 PM, the administrator stated that the charge nurse was responsible for making sure that a residents foley catheter bag was secure. She stated that a foley catheter bag that was not secure can cause tears to the skin and cause pain. She expects the charge nurse to make sure foley catheters are secured and properly positioned. Record review of facility policy titled Catheter Care, Urinary dated January 3, 2023, indicated, .ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 7 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 (Resident #43) residents reviewed for intravenous fluids. Residents Affected - Few The facility failed to ensure Resident #43 received PICC (a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes with a dressing dated 12/28/2023 This failure could affect residents by placing them at risk for infection. Findings included: Record review of an admission Record dated 1/10/2024 for Resident #43 indicated he admitted to the facility on [DATE] with a recent admission date of 12/31/2023 and was [AGE] years old with diagnoses of hemiplegia and hemiparesis (paralyzed on one side of the body), diabetes and osteomyelitis (infection in the bone). Record review of a Quarterly MDS Assessment for Resident #43 dated 12/4/2023 indicated he had severe impairment in thinking with a BIMS score of 4. He had an active diagnosis of septicemia (blood infection). He received IV medications and IV access during the last 14 days look back period as a resident. Record review of a care plan for Resident #43 dated 11/30/2023 with a revision on 1/8/2024 indicated he was on long term antibiotics for infection post-surgical with interventions to administer antibiotic therapy as prescribed. The care plan did not address PICC line maintenance. Record review of active physician orders for Resident #43 dated 1/10/2024 indicated to change PICC dressing every seven days or as indicated for soiled or damaged dressing with a start date of 1/10/2024. During an observation and interview on 1/10/2024 beginning at 8:42 am in Resident #43's room LVN E was present to administer IV antibiotics. Resident #43 had two visible ports and the PICC line dressing was covered with an off-white colored bandage. LVN E said the dressing was covered because Resident #43 had pulled the PICC line out a couple of times and they were keeping it covered up to help prevent him from removing it. This surveyor asked LVN E to pull the bandage down so the dressing could be observed and the PICC line had a clear adhesive dressing dated 12/28/2023. LVN E accessed the PICC line to Resident #43's right upper arm to infuse Cefepime 2 gram/100 ml without any break in infection control. When LVN E was questioned about who changed the PICC line dressings, she said the dressings should be changed by the RN's weekly but the LVN's could also change them. During an interview on 1/10/2024 at 9:42 AM, the Regional Nurse said a nurse was responsible for changing the PICC line dressings per physician orders. She said the resident should have orders for PICC line dressing changes and to monitor the site. She said Resident #43 did not have any orders in the charting system and would have the nurse change the dressing. She said the nurse that received the orders from the physician were responsible for entering the orders. She said a resident could be at risk for infection if the PICC line dressings were not changed per the physician orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 8 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 0694 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/10/2024 at 9:45 AM, the DON said the RN's were responsible for PICC line dressing changes every 7 days. She said the nurse who admitted the resident was responsible for entering orders. She said going forward she would conduct an audit for all new admissions along with the clinical team. She said residents could be at risk for infection. She said she was not aware that Resident #43's PICC line dressing had not been changed since 12/28/2023. Residents Affected - Few During an interview on 1/10/2024 at 3:15 PM, the Administrator the PICC line dressing changes were supposed to be change per the order. She said the nurses needed to follow physician orders and infections could develop. She said the DON/ADON were responsible for ensuring nurses were following the orders. Record review of a facility policy titled Midline Dressing Changes with a revised date of April 2016 indicated, .The purpose of this procedure is to prevent catheter-related infection associated with contaminated, loosened or soiled catheter-site dressings. 1. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 9 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 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 ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that: Residents Affected - Many During the initial observation on in the kitchen the low temperature, chemical sanitation dish machine, did not reach the manufacturer's recommended minimal water temperature of 120 degrees Fahrenheit, (F) during the final rinse cycle This failure could place the residents at risk of foodborne illnesses. Findings included: During an observation and interview 01/08/24 beginning at 9:15 a.m., DA-N was standing at the dish machine washing the breakfast dishes, he said he had worked at the facility for two years. He said he was trained to test the machine by the DM. Upon request the DA-N tested the dish machine, and it tested at 50 parts-per-million, (PPM), of hypochlorite (chlorine), and the water temperature read 111 degrees Fahrenheit, (F). DA-N ran the machine five times to try to get the water temperature up to required 120 degrees Fahrenheit, (F). On the fourth time the machine reached 118 degrees F, but on the fifth time it dropped back down to 116 degrees F. DA-N said the dish machine had been having a problem reaching the required 120 degrees F, for a while. He said he ran the dishes through the machine three times to make sure they were sanitized. The Surveyor notified the DM that the facility could not use the dish machine until the water reached the minimum required water temperature of 120 degrees F. During an interview 01/08/24 at 9:30 a.m., DM said she had worked at the facility for four years, she said they had been having problems with the machine not reaching the proper temperature since October. She said they had a plumber come out and replaced a hot water heater, because they thought the old hot water heater wasn't large enough to provide hot water to the washing machines in the laundry, and the dish machine in the kitchen. Then an electrician came out and replaced a plug because they thought maybe it wasn't getting enough power. She said last week they ordered a hot water booster for the machine, but it had not come in yet. She said the staff were trained not to use the machine if it was not reading at the proper temperature. She said the dish machine not sanitizing the dishes could make the residents sick. During a phone interview 01/09/24 @ 8:36 a.m., the service representative, for the machine said the facility never notified them of the machine's low water temperature reading, if they had they could adjust the sanitizer level up to compensate for the low water temperature. He said the manufacture's recommendations for a low temperature chemical sanitation machine's minimal water temperature, should reach 120 degrees F. During an interview on 01/09/24 @ 10:30 a.m., the Administrator said they had ordered a booster for the dish machine on 12/29/23 and was waiting for it to be delivered. When asked why they didn't stop using the machine she said she makes rounds in the kitchen every morning. She said she checks the log on the wall to make sure the staff had tested the machine. She said they were aware at times of the machine losing temperature, that was the reason they ordered the booster. She said the staff know and are trained to not use the machine if it is not reading at proper temperature. She said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 10 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 was never aware that the machine was used when it wasn't sanitizing correctly. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/10/24 at 2:52 p.m., the Administrator said the DM would be responsible for in servicing the staff, and she expected the staff to test the dish machine before use as required. She said if the dish machine was not working, she needs them to call out the service technician to test the machine. She said moving forward she would continue to check logs every morning and once a week she would monitor staff testing the machine for accuracy. She said the dishes not being sanitized could make the residents sick. Residents Affected - Many Review of a policy titled Dish machine Use; revised March 2010 indicates: 7. The operator will check temperatures using the gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. 9. If hot water temperature or chemical sanitation concentrations do not meet requirements, cease use of the machine immediately until temperature or PPM of sanitizer are adjusted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 11 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 observations, interviews, and record reviews, 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 2 of 6 residents (Resident # 25 and Resident #286) reviewed for infection control. Residents Affected - Few The treatment nurse failed to perform proper hand hygiene while providing wound care to Resident #25 on 01/10/2024. CNA C failed to perform proper hand hygiene while providing incontinent care to Resident #286 on 01/09/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a facility face sheet for Resident #25 revealed Resident #25 was readmitted on [DATE] with diagnosis of dysphagia (difficulty swallowing). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #25 had a BIMS of 06 indicating severely impaired cognition, required maximal assistance with all ADL's and had pressure ulcers (sores to the skin). Record review of a comprehensive care plan dated 11/29/2023 revealed Resident #25 had an ADL self-care deficit and required total care for all ADL's and had a pressure ulcer to the sacrum (tailbone) with goal for wound to remain free from infection. Record review of a physician's order dated 11/19/2023 indicated Resident #25 to receive wound care to pressure ulcer to sacrum every day. 1. During an observation on 01/10/2024 at 9:30 am, the treatment nurse and ADON provided wound care to Resident # 25. During wound care the treatment nurse did not wash or sanitize her hands between glove changes 2 out of 3 times. During an interview on 01/10/2024 at 9:42 am, the treatment nurse stated she had been providing wound care at the facility since March 2023 and had been trained on infection control. She stated she should have washed or sanitized her hands between glove changes for infection control measures. She stated by not doing so could cause infections to the resident. During an interview on 01/10/2024 at 9:46 am, the ADON stated she was responsible for staff training since November 2023. She stated that proper hand washing, and sanitization was including in the infection control training, and she expected that all staff know the proper technique when using gloves to prevent the spread of infections. 2. Record review of a facility face sheet for Resident #286 revealed Resident #286 was admitted on [DATE] with diagnosis of muscle wasting and atrophy (weakness and breakdown of muscles). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 12 of 13 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 455673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904 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 Record review of an admission MDS assessment dated [DATE] revealed Resident #286 had a BIMS of 04 indicating severely impaired cognition and required maximal assistance with toileting hygiene. Record review of a comprehensive care plan dated 12/07/2023 revealed Resident #286 had an ADL self-care deficit and required total assistance with toileting. Residents Affected - Few During an observation on 01/09/2024 at 8:42 am, CNA C and CNA D performed incontinent care for Resident # 286. Both CNA's washed their hands and applied clean gloves before starting incontinent care. CNA C removed Resident #286's brief from the front and cleaned the perineum with wipes. CNA D rolled Resident #286 to her left side and CNA C removed her soiled gloves and placed clean gloves without washing or sanitizing her hands in between glove change. CNA C cleaned the back region and buttocks of Resident # 286 using wipes and removed soiled brief. CNA C then placed the soiled brief in a trash liner and removed her gloves. CNA C placed new gloves without washing or sanitizing hands in between glove change. CNA C then applied a new brief under Resident #286 and CNA D assisted Resident #286 back to her back and CNA C resumed pulling brief up and fastened the brief in place. Both CNA's removed their gloves and washed their hands before leaving resident #286's room. During an interview on 01/09/2024 at 8:50 am, CNA C stated she had been a CNA for 10 years and was knowledgeable on incontinent care. She stated she should have washed or sanitized her hands in between glove changes but was nervous. She stated by not performing proper hygiene with glove changes it could cause infections. During an interview on 01/09/2024 at 8:55 am, CNA D stated she had been a CNA for 11 years and she had been trained on incontinent care. She stated that when changing gloves, you should always wash or sanitize your hands in order to prevent infections. During an interview on 01/09/2024 at 12:25 pm, the ADON stated she was responsible for CNA competencies including incontinent care. She stated on hire and annually CNA's are trained and checked off on competencies. She stated she has only been in the position for 2 months and had not done one on one reviews with the CNA's but each of them had been previously trained. She stated if incontinent care was not completed following infection control measures the resident would be at risk for infections. During an interview on 01/10/24 at 2:52 pm, the DON stated the ADON was responsible for all training and competencies as well as herself. She stated there was an outside vendor that provided hands on training for infection control a few months ago. She stated that staff should always wash or sanitize their hands between glove changes to prevent infections and expected all staff to follow the infection control procedures. During an interview on 01/10/24 at 3:15 pm, the administrator stated infection control was the responsibility of the DON, but everyone was expected to follow infection control measures. She stated if infection control measures were not followed, infections could occur and expected that infection control and handwashing policies were followed. Record review of the facility's policy titled Handwashing/Hand Hygiene dated August 2019 indicated, .7. use an alcohol-based hand rub or soap and water for the following situations: m. after removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455673 If continuation sheet Page 13 of 13