Health inspection·August 31, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm During an observation on 08/29/23 at 10:34 a.m., revealed Resident #98 was in the bed and his call light was placed near his contracted right hand. During an observation on 08/29/23 at 6:36 p.m., revealed Resident #98 was in the bed and his call light was on the floor. Residents Affected - Few During an observation on 08/30/23 at 8:56 a.m., revealed Resident #98 was in the bed and his call light was on the floor. During an observation on 08/31/23 at 8:00 a.m., revealed Resident #98 was in the bed and his call light was hanging off the side of the bed, not within reach. During an observation on 08/31/23 at 9:20 a.m., revealed Resident #98 was in the bed and his call light was hanging off the side of the bed, not within reach. 2. Record review of a face sheet dated 08/28/23 indicated Resident #267 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including contractures (is a fixed tightening of muscle, tendons, ligaments, or skin) of right and left shoulder, right and left elbow, right and left hand, left and right knee, limitation of activities due to disability, muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), contracture of muscle of left and right hand, and hypoxic ischemic encephalopathy (is a condition that happens when there is a loss of oxygen and/or reduced blood flow to the brain). Record review of an annual MDS assessment dated [DATE] indicated Resident #267 was rarely/never understood and rarely/understood others. The MDS indicated Resident #267 had adequate hearing and no speech. The MDS indicated Resident #267 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #267 had short-and-long term memory problems with severely impaired cognitive skills for daily decision making. The MDS indicated Resident #267 required extensive assistance for personal hygiene and total dependence for bed mobility, dressing, eating, toilet use, and bathing. The MDS indicated Resident #267 had bilateral (both sides) upper and lower extremities limited range of motion. The MDS indicated Resident #267 was always incontinent for urinary and bowel. Record review of a care plan dated 11/19/20 indicated Resident #267 was low risk for falls related to no independent movement. Intervention included be sure the resident's call light was within reach and encourage use for assistance as needed. Record review of a care plan dated 02/21/22 indicated Resident #267 had alteration in musculoskeletal status related to bilateral hand contractures due to immobility and disease process. Intervention included apply hand rolls to bilateral hands as recommended. During an observation on 08/28/23 at 9:49 a.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths. During an observation on 08/28/23 at 3:19 p.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 2 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0558 Level of Harm - Minimal harm or potential for actual harm During an observation on 08/29/23 at 8:34 a.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths. During an observation on 08/29/23 at 10:36 a.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths. Residents Affected - Few During an observation on 08/29/23 at 3:05 p.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths. During an interview on 08/30/23 at 9:03 a.m., CNA A said call lights should be within reach of the residents. She said Resident #98 and Resident #267 should have a touch pad call light instead of the push button. CNA A said the call lights were important for residents to get assistance or call for help. She said all nursing staff was responsible for ensuring call lights were within reach. CNA A said she did not know how residents were assessed to determine if they needed a different type if light. During an interview on 08/30/23 at 2:07 p.m., LVN D said everyone was responsible for making sure call lights were within reach. She said call lights were used so the resident could get help, let staff know if they were in pain or needed incontinence care. LVN D said a touch pad call light would be good for Resident #98, but she did not know if Resident #267 could use a call light. She said the DON should be notified if a resident needed a different type of call light. LVN D said the appropriate type of call lights were important to accommodate the needs of the resident. During an interview on 08/30/23 at 5:36 p.m., the OT Director said she went to evaluate Resident #98 and Resident #267, and they both could push the call light button. During an interview on 08/31/23 at 8:20 a.m., LVN C said everybody was responsible for making sure call lights were within reach. She said nurses were responsible for making sure the resident had the appropriate type of call light. LVN C said Resident #98 and Resident #267 could use the push button call lights. She said she had notified therapy to evaluate Resident #267 to make sure he had the right call light, but she could not remember when. LVN C said the facility recently had a new company take over the therapy department so she could not remember who she told. She said Resident #267 normally had hand rolls and were taken out every 2 hours or so. LVN C said she could see when Resident #267 had hands rolls in place, a push button call light would not work for him. She said call lights were used to call for assistance or when in distress. LVN C said when call lights were not within reach, falls could happen. During an observation on 08/31/23 at 9:16 a.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths. During an interview on 08/31/23 at 9:45 a.m., the DON said all staff were responsible for making sure call lights were within reach. She said a resident admitted with contractures should be evaluated by therapy for call light appropriateness. The DON said after admission, it was a team effort to assess the resident to make sure they had the right type of call light. She said without personally evaluating Resident #98 and Resident #267, she could not say which call light was appropriate for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 3 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few them. The DON said call lights were important to take care of the resident's needs. She said all staff should oversee each other to ensure call lights were placed within reach. The DON said when call lights were not within reach or not the right type of call light, needs cannot be met timely. During an interview on 08/31/23 at 10:41 a.m., the ADM said facility staff were responsible for placing call lights within reach and ensure they were appropriate for the resident. He said call lights were important because residents used them to call for help. The ADM said charge nurses, managers, and facility ambassadors should be overseeing by making rounds. He said call lights not being in reach placed residents at risk for falls or needs not being met. Record review of a facility Resident Rights-Accommodation of Needs policy date revised 08/20 indicated to ensure that the facility provided an environment and services that meet residents' individual needs FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 4 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 - Some 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, record review and interview, the facility failed to consult with the resident physician when there was a need to alter treatment for 1 out of 3 residents (Resident #61) reviewed for notification of changes. The facility failed to notify and consult with the physician about the changes in Resident #61's high blood sugar readings. This failure could place residents at the risk of not receiving appropriate medical interventions, which could result in severe illness or hospitalization. Findings included: Record review of Resident #61's face sheet, dated 09/05/23 indicated Resident #61 was an [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), diabetes (a condition that happens when your blood sugar (glucose) is too high) and seizures (when too many of your brain cells become excited at the same time). Record review of Resident #61's quarterly MDS assessment, dated 08/04/23, indicated Resident #61 was understood and understood others. Resident #61's BIMs score was 14, which indicated he was cognitively intact. Resident #61 required extensive assist with bathing, and limited assist with eating and independent with toileting, personal hygiene, transfer, dressing, and bed mobility. The MDS indicated Resident #61 received insulin during the 7-day look back period. Record review of Resident #61's comprehensive care plan, dated 04/12/23 indicated Resident #61 required insulin products related to diagnosis of diabetes. The interventions of the care plan were for staff to provide Resident #61 with medications as ordered, check blood sugars as ordered and monitor for any signs or symptoms of low or high blood sugars due to new diagnosis and use of insulin. Record review of Resident #61's physician's orders dated 04/10/23 indicated, Humalog injection solution 100units/ml(lispro). Inject 10 units subcutaneously with meals for diagnosis of diabetes with blood sugar checks before meals Record review of Resident #61's physician's orders dated 04/17/23 revealed, Lantus Solostar subcutaneous injection 100units/ml. Inject 20 units subcutaneously in the morning for diagnosis of diabetes. Record review of Resident #61's physician's orders dated 04/17/23 revealed, Lantus Solostar subcutaneous injection 100units/ml. Inject 15 units subcutaneously in the evening for diagnosis of diabetes. Record review of Resident #61's MAR dated August 2023 documented by LVN S revealed a high blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 5 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 - Some sugar over 400 on the following days and times: 417 on 8/22/23 at 12:00pm, 410 on 8/26/23 at 12:00pm, 510 on 08/27/23 at 12:00pm and 404 on 08/28/23 at 12:00pm and documented by LVN T 400 on 08/26/23 at 7:00am. Record review of Resident #61's progress notes dated August 2023 did not reveal any notes regarding blood sugars over 400 were reported to the physician or NP. During an interview on 08/30/23 at 11:10 a.m., Resident #61 said staff did let him know about his blood sugars but he did not understand why some of his blood sugar readings were high. During an observation and interview on 08/30/23 at 2:41 p.m., LVN R said if Resident #61's blood sugar was over 401 she would notify the doctor. She looked on his MAR and saw some of his recent blood sugars were over 400 and then looked at his nurses notes and did not see any notification to the physician. LVN R said she would notify the physician about Resident #61's high blood sugar readings. She said it was important to notify the physician of high blood sugar results to prevent any further damage to his kidneys or other organs of his body. During a phone interview on 08/30/23 at 2:53 p.m., the facility NP said he was just informed by LVN R of Resident #61's blood sugar readings. He said he expected staff to notify him of blood sugar readings below 60 and above 400. He said he communicated to the primary physician about any changes provided for the facility. He said he amended Resident #61's insulin. He said untreated hyperglycemia over a period could lead to organ damage. Record review of Resident #61's physician's orders dated 08/30/23 revealed, Lantus Solostar subcutaneous injection 100units/ml. Inject 30 units subcutaneously in the morning. Record review of Resident #61's physician's orders dated 08/30/23 revealed, Lantus Solostar subcutaneous injection 100units/ml. Inject 20 units subcutaneously in the evening. During a phone interview on 08/30/23 at 3:49 p.m., LVN S said if a resident's blood sugar reading was over 400, she would notify the physician or NP. She said she was Resident #61's primary nurse but did not remember Resident #61's blood sugars being high. She said she did not remember notifying the doctor about his blood sugars over the weekend (08/26/23-08/27/23) or on Monday (08/28/23). LVN S said it was important to notify the doctor or NP of high blood sugar reading because a resident could go into a diabetic coma. During an interview on 08/30/23 at 4:41 p.m., ADON H said an order to notify the physician or NP of low or high blood sugars was usually in the orders. She said if they did not have an order, she would use best practice and notify the doctor of any blood sugar readings over 400. The ADON H said a high blood sugar reading could cause further issues with diabetes if not under control. During an interview on 08/30/23 at 4:57 p.m., the DON said the physician or NP should be notified of blood sugars over 400. She said the unit managers should be monitoring MARS daily, and NP/physicians reviewed when making rounds. The DON said if blood sugars remain uncontrolled a resident could have adverse effects. During an interview on 08/30/23 at 5:24 p.m., the Administrator said he was unaware when the physician should be notified of blood sugars, but he said nurses should be following the parameters set by the physician. He said nurse managers and the DON should be monitoring blood sugars readings. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 6 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 - Some Administrator said if a resident had a change in condition, then the nurses should be notifying the physician. Record review of the facility policy for Blood Glucose Monitoring revised 06/2020, indicated, Purpose: to monitor blood glucose concentration as ordered by the attending physician. Policy: the attending physician will be notified of a blood sugar lower than 60 or higher than 400, unless otherwise indicated in the plan of care. Record review of the facility policy for Notification of physician revised 06/2020, indicated, To ensure residents, family, legal representative, and physicians are informed of changes in the resident's condition in a timely manner. Definition: an acute change of condition was a sudden, deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. The facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to a significant change in residents' physical cognitive behavior or functional status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 7 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0583 Keep residents' personal and medical records private and confidential. 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 residents had a right to personal privacy and confidentiality of medical records for 2 (Resident #81 and Resident #5) of 7 residents reviewed for privacy and confidentiality. Residents Affected - Few ADON K failed to ensure she closed the EMR of Resident #81 before entering his room to obtain a blood sugar check and administer medications. LVN V failed to ensure she closed Resident #5's EMR before entering the supply room and leaving the cart unattended. These failures could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others. Findings included: 1. Record review of Resident #81's face sheet dated 08/30/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis that affects all four limbs, plus torso), diabetes mellitus (a group of diseases that result in too much sugar in the blood), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety. Record review of Resident #81's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #81 had a BIMS score of 15, indicating his cognition was intact. The MDS indicated he was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated he received insulin injections 7 out of the 7 days of the look back period. During an observation on 08/29/23 at 08:30 AM, revealed ADON K entered Resident #81's room to obtain a blood sugar check. ADON K left Resident #81's MAR screen open on her cart facing toward Resident #81's room but far enough someone could have stopped visualized it. ADON K came back to the cart and obtained Resident #81's medications. After obtaining Resident #81's medications, ADON K entered his room to administer the medications leaving the MAR screen open. A staff member came next to the cart waiting on ADON K. Multiple staff members were observed passing down the hallway. During an interview on 08/29/23 at 08:59 AM, ADON K said it was the nurse's responsibility to keep EMR locked when not present. ADON K said she forgot to lock the screen and someone could have seen the resident's information. 2. Record review of Resident #5's face sheet dated 08/30/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (memory loss), neuromuscular dysfunction of bladder (bladder dysfunction caused by nervous system conditions), diabetes mellitus (a group of diseases that result in too much sugar in the blood) and essential hypertension (high blood pressure). Record review of Resident #5's annual MDS assessment dated [DATE], indicated Resident #5 had unclear speech, was usually understood and usually understood others. The MDS indicated Resident #5 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 8 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few BIMS score of 5, which indicated her cognition was severely impaired. The MDS indicated Resident #5 required extensive assistance with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. During an observation and interview on 08/29/23 at 09:17 AM, the 316-331 medication cart was parked outside room [ROOM NUMBER], a supply room. The MAR for Resident #5 was open, turned toward the hall and visible with her information. There was not a staff member present. LVN V came out of the supply room, and said she was the one responsible for leaving the screen with the MAR open. LVN V said she quickly ran to the supply room to obtain a syringe and did not think about closing Resident #5's EMR. LVN V said she was responsible for ensuring the EMR screen was kept locked when not present. LVN V said by not locking the EMR screen the resident's personal information could be seen by others passing by . During an interview on 08/30/23 at 4:50 PM, the ADM said he expected the MAR screen to be closed when the nurses entered the resident's room or if they left the cart unattended. The ADM said it was a HIPPA violation and breech of resident information leaving the screen with resident information up and visible to others. The ADM said everyone was responsible for ensuring resident information was kept confidential. During an interview on 08/30/23 at 5:22 PM, the DON said she expected the EMR screen to be locked and the resident's information to be kept confidential. The DON said the nurse was responsible for ensuring the screen was kept locked when not in use. The DON said by not keeping the screen locked was a privacy and confidentially issue. Record review of the facility's policy General Guidelines for Medication Administration revised on 08/2020, indicated . privacy is maintained for all resident information at all times by closing the MAR when not in use FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 9 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of a face sheet dated 8/30/23 indicated Resident #23 was [AGE] year-old female and admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), unsteadiness on feet, and need for assistance with personal care. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated Resident #23 had adequate hearing, clear speech, and impaired vision. The MDS indicated Resident #23 had a BIMS score of 15 which indicated intact cognition and only required supervision for dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #23 was always continent for urinary and bowel. Record review of a care plan with revision date of 6/19/23 indicated Resident #23 had an ADL self-care performance deficit related to impaired vision. Resident #23 was able to do most ADLs with supervision or setup assist. Intervention included toilet use: Resident #23 required 1 person assist for toileting. During an observation and interview on 8/29/23 at 8:41 AM, Resident #23 said housekeepers cleaned the bare minimum when they did show up. She said no one has emptied her bathroom trash since Friday (8/25/23) and no one had cleaned the bathroom in a few weeks. Resident #23's toilet bowel had light brown streaks and the trash can was ¾ full. During an interview on 8/30/23 at 9:03 AM, CNA A said there was no housekeeping the past weekend, so she was not surprised Resident #23's bathroom was not cleaned. CNA A said an unclean bathroom had germs which was not good for residents. During an interview on 8/30/23 at 2:07 PM, LVN D said Resident #23 complained about her bathroom not being cleaned regularly. During an interview on 8/31/23 at 8:20 AM, LVN C said housekeeping should clean residents' bathrooms daily. She said it was important for residents to have a clean, homelike environment without germs. 4. Record review of a face sheet dated 8/28/23 indicated Resident #267 was a [AGE] year-old male and admitted on [DATE] with diagnoses including dysphasia (difficulty swallowing foods or liquids) following cerebral infarction (stroke) and protein calorie malnutrition (is the state of inadequate intake of food). Record review of an annual MDS assessment dated [DATE] indicated Resident #267 was rarely/never understood and rarely/understood others. The MDS indicated Resident #267 had adequate hearing and no speech. The MDS indicated Resident #267 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #267 had short-and-long term memory problems with severely impaired cognitive skills for daily decision making. The MDS indicated Resident #267 required extensive assistance for personal hygiene and total dependence for bed mobility, dressing, eating, toilet use, and bathing. The MDS indicated Resident #267 had a feeding tube (is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) and received calories and fluid intake through it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 10 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the care plan with revision date of 8/25/21 indicated Resident #267 required tube feeding related to respiratory failure (is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with PEG (a percutaneous endoscopic gastrostomy (PEG) is a procedure to place a feeding tube) status secondary to anoxic brain injury (the brain is deprived of oxygen). Record review of the Resident #267's consolidated physician's order dated 11/28/22 indicated Enteral feed order every shift continuous: Formula: Glucerna 1.5 at 65 ml/hr with H2O at 42 ml/hr x 22 hours. During an observation on 8/28/23 at 9:49 AM, revealed Resident #267 had a feeding pump running with enteral formula. Resident #267 had a large amount of dried, beige substance on the floor, bottom of the IV pole, feeding pump plug, wall, and bed. During an interview on 8/30/23 at 9:03 AM, CNA A said whoever initially spilled Resident #267's formula should have cleaned it up. She said housekeeping and CNAs should have also cleaned the spillage. She said wasted formula could draw pests and made the room look terrible. CNA A said Resident #267's room was not sanitized with dried formula everywhere. During an interview on 8/30/23 at 10:45 AM, the Housekeeping Supervisor said one weekend day, there was no housekeeper working. She said the housekeepers should clean residents' rooms and bathrooms daily. The Housekeeping Supervisor said she had not seen the formula on Resident #267's floor. She said she was responsible for making sure her staff cleaned rooms and bathrooms daily. The Housekeeping Supervisor said she asked her staff if they cleaned daily and checked behind them. She said not cleaning residents' rooms and bathrooms could cause buildup of bacteria, mildew, and smells. The Housekeeping Supervisor said uncleanness placed resident at risk for infections. During an interview on 8/30/23 at 2:07 PM, LVN D said she did not notice the formula on Resident #267's floor. She said the nurse who spilled the formula should have cleaned it and housekeeping. LVN D said spilled formula was unsanitary. During an interview on 8/31/23 at 8:20 AM, LVN C said the nurses and housekeeping were responsible for cleaning the spilled formula. She said the spilled formula attracted pests and germs and could lead to a fall. During an interview on 8/31/23 at 9:45 AM, the DON said Resident #267 had formula on the floor, IV pole, and walls. She said LVNs and aides should clean the formula up when it happened. The DON said the formula had become hardened, they had to replace the IV pole because it would not come off. She said it was important for the residents to have a clean environment. The DON said nursing administrators and housekeeping supervisors should oversee the cleanness of the facility by doing rounds. She said housekeeping was responsible for cleaning resident's toilets and emptying trash to promote cleanliness. The DON said the housekeeper should follow their cleaning schedule and the housekeeping supervisor should make rounds to ensure it was being done. During an interview on 8/31/23 at 10:41 AM, the ADM said he expected the facility to be cleaned as indicated. He said all facility staff were responsible for a clean environment. The ADM said administration and housekeeping supervisor should ensure it happened. He said a clean environment was important for cleanliness, infection control, and to prevent accidents and hazards. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 11 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a facility policy titled, Maintenance Services-Physical Environment with a revised date of August 2020 indicated . protect the health and safety of residents, visitors, and facility staff . maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . maintaining the heat/cooling system . maintaining all mechanical, electrical, and patient care equipment in safe operating condition . providing routinely scheduled maintenance service to all areas . Director of Maintenance was responsible for developing and maintaining a schedule of maintenance service to assure that buildings, grounds, and equipment were maintained in a safe and operable manner . responsible for conducting regular inspections that may include . resident . maintenance staff follow established safety regulations to ensure the safety and well-being of all concerned Review of a facility policy titled, Resident Rooms and Environment with a revised date of August 2020 indicated . to provide residents with a safe, clean, comfortable and homelike environment . ensuring that residents could receive care and services safely and the physical layout of the facility maximizes resident independence and did not pose a safety risk . facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following . cleanliness and order . comfortable levels of ventilation Based on observation, interview, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment 4 of 35 residents reviewed for environment. (Resident #34, Resident #73, Resident #23, and Resident #267) 1. The facility failed to ensure Resident #34 and Resident #73's portable air conditioning unit/filter was free of gray fuzz and dust-like particles. 2. The facility failed to ensure Resident #34's fan was free of gray fuzz and dust-like particles. 3. The facility failed to ensure Resident #23's bathroom was cleaned daily. 4. The facility failed to ensure Resident #267 did not have enteral feeding (also known as tube feeding, is a way of delivering nutrition directly to your stomach or small intestine) on the floor, IV pole, wall, and mattress. These failures could place residents at risk of an unsafe, unsanitary, or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: 1.Record review of Resident #34's face sheet dated 8/29/23 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #34 had diagnoses of shortness of breath, heart failure, reduced mobility, hypertension, diabetes, weakness, dependent on supplemental oxygen, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 12 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some obstructive sleep apnea (blockage in airway keeps air from moving through the windpipe during sleep), and chronic bronchitis (long-term inflammation of the airways). Record review of Resident #34's quarterly MDS, dated [DATE], indicated Resident #34 had clear speech and was understood by staff. The MDS indicated Resident #34 was able to understand others. The MDS indicated Resident #34 had a BIMS of 12, which indicated moderate cognitive function impairment. The MDS revealed Resident #34 required extensive assistance of 1-2 persons for most ADLs. Record review of Resident #34's undated care plan revealed she received oxygen therapy related to respiratory failure and chronic bronchitis and she had altered respiratory status/difficulty breathing related to sleep apnea. During an observation and interview on 8/28/23 at 10:15 AM, revealed Resident #34 was sitting up in bed with oxygen on at 4 LPM by NC. Resident #34 had a black fan sitting on a desk at the end of her bed blowing directly at her and the fan casing and blades were covered in gray fuzz and dust-like particles. Resident #34 had a portable air conditioning unit in her room that she shared with Resident #73. The portable air conditioning unit was at the end of Resident #34's bed with a white flex tubing that vented out the window, and the unit was pointed to blow across the room. The portable air conditioning unit had significant dust-like particles on it and the filter on the back of the unit was heavily covered in gray fuzz and dust-like particles. Resident #34 said no one had cleaned the portable air conditioning unit or cleaned the filter to her knowledge. Resident #34 said she needed lots of air flow in her room because of her breathing problems. During an observation on 8/29/23 at 9:35 AM revealed Resident #34's black fan that was blowing directly toward Resident #73 continued to be covered in gray fuzz and dust-like particles. 2. Record review of Resident #73's face sheet dated 8/29/23 revealed he was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #73 had diagnoses of COPD, shortness of breath, respiratory failure, weakness, heart failure, and pulmonary fibrosis (lung disease where lung tissue becomes damaged and scarred, thickened and stiff making it harder for lungs to work properly). Record review of Resident #73's annual MDS dated [DATE] revealed he was understood and understood others. Resident #4 had a BIMS of 15, which indicated he was cognitively intact. Resident #73 required limited to extensive assistance of 1 person for most ADLs. Resident #73 had shortness of breath when lying flat and received oxygen therapy. Record review of Resident #73's undated care plan revealed he had shortness of breath related to respiratory failure, altered respiratory status/difficulty breathing related to respiratory failure and COPD. During an observation and interview on 8/28/23 at 10:28 AM, revealed Resident #73 was lying in bed with his oxygen on at 4 LPM by NC. Resident #73 shared a room with Resident #34 and there was a portable air conditioning unit was at the end of Resident #34's bed with a white flex tubing that vented out the window, and the unit was pointed to blow across the room. Resident #73's bed was located across the room closest to the door. The portable air conditioning unit had significant dust-like particles on it and the filter on the back of the unit was heavily covered in gray fuzz and dust-like particles. Resident #73 agreed that no one had cleaned the portable air conditioning unit or cleaned the filter to his knowledge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 13 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 8/29/23 at 9:35 AM revealed Resident #34 and Resident #73's portable air conditioning unit continued to have significant dust-like particles on it and the filter on the back of the unit was heavily covered in gray fuzz and dust-like particles. During an interview on 8/30/23 at 8:17 AM, LVN G said she had worked at the facility for eight years and usually worked day shift on Hall 200. LVN G said staff would tell the Maintenance Supervisor if a resident's fan needed to be cleaned. She said maintenance would be responsible for cleaning the portable air conditioning unit and filters to ensure the unit was functioning properly. During an interview on 8/30/23 at 8:36 AM, ADON H said she had worked at the facility for three years. ADON H said she was responsible for ensuring everything was going smoothly and everyone was doing what they were supposed to do. ADON H said she did not know who was responsible for cleaning the fans in the residents' rooms or the portable air conditioning unit/filter, but she said she would find out. ADON H said a dirty fan blowing towards a resident increased their risk of respiratory issues. ADON H said the dirty portable air conditioning unit and filter could affect how the unit worked and not be able to filter contaminates from the air in the resident's room. During an interview on 8/30/23 at 9:07 AM, the Maintenance Supervisor said all staff were responsible for maintaining the portable air condition unit. The Maintenance Supervisor said the portable air conditioner unit filter should be cleaned at least monthly by housekeeping or the maintenance department. The Maintenance Supervisor said he did not have cleaning the portable air conditioning unit's filter on the maintenance schedule, but he would be adding it to the schedule to ensure the filter was cleaned monthly. The Maintenance Supervisor said a full dirty air conditioning filter would not allow the unit to work correctly and it could affect the resident's breathing due to the dust. The Surveyor showed the Maintenance Supervisor a picture of the portable air conditioning filter and he said it did not look like it had been cleaned in a month or longer. The Maintenance Supervisor said housekeeping or the maintenance department should be cleaning the fan shields and blades, but any staff member could do it. The Maintenance Supervisor said dirty fans could cause respiratory issues for the residents. During an interview on 8/30/23 at 9:29 AM, ADON K said she had worked at the facility since November 2022. ADON K said the maintenance department was responsible for cleaning the residents' fans and the portable air conditioner/filters. ADON K said residents could get respiratory infections due to the dust and pollution. During an interview on 8/30//23 at 2:37 PM, the Housekeeping Supervisor said she had worked at the facility since December 2022 in housekeeping, but she had been the Housekeeping Supervisor for about a month. The Housekeeping Supervisor said housekeeping was responsible for dusting the residents' fans daily with the housekeeping task. The Housekeeping Supervisor said she expected her housekeeping staff to do a deep clean of the residents' rooms daily to include changing the trash, wiping the bed frames and call lights down, dusting the light fixtures, wiping down the tabletops and walls, bathroom mirrors, cleaning the toilets, everything should be wiped down and clean. The Housekeeping Supervisor said housekeeping should include cleaning the air conditioning filter in the residents' rooms. The Housekeeping Supervisor said she was new to the supervisor role and was working on training staff and improving the housekeeping department. During an interview on 8/30/23 at 4:37 PM, the DON said she had worked at the facility for three years. The DON said the maintenance department or housekeeping would be responsible for ensuring the resident's fan was clean and for cleaning the portable air conditioning unit/filter. The DON said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 14 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete dirty fans and dirty air conditioning filters could lead to a bacteria build up and could cause the residents respiratory issues. During an interview on 8/30/23 at 5:34 PM, the Administrator said he would expect the staff to ensure the residents' fans and the portable air conditioning unit/filter to be clean and free of dust in the residents' room. The Administrator said the residents could have respiratory issues related to dirty fans and dirty portable air conditioning units/filters. Event ID: Facility ID: 675133 If continuation sheet Page 15 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 7 residents reviewed for care plans. (Resident #72, Resident #98) The facility failed to implement the care plan intervention to document Resident #72 and Resident #98's meal intake. The facility failed to implement the care plan intervention for Resident #98 to receive his Frozen Nutritional Treats with meals. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services Findings included: 1. Record review of a face sheet dated 08/30/23 indicated Resident #72 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including Parkinson's (is a movement disorder. It causes tremors, stiffness, and slow movement), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and fracture of left femur (is a break in the thighbone). Record review of an admission MDS assessment dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated Resident #72 had a BIMS score of 12 which indicated moderately impaired cognition and required supervision for eating, extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident #72 had nutritional malnutrition. Record review a care plan dated 06/06/23 indicated Resident #72 had potential nutritional problem/malnutrition related to Alzheimer's, Parkinson's, poor dental health, and admission to nursing facility. Intervention included provide, serve diet as ordered. Monitor intake and record every meal. Record review of Resident #72's Amount Eaten report dated 08/30/23 indicated no meal intake amount for: *08/28/23: 9:00 am, 1:00 pm *08/29/23: 9:00 am, 1:00 pm *08/30/23: 9:00 am, 1:00 pm 2. Record review of a face sheet dated 08/28/23 indicated Resident #98 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), muscle weakness, need for assistance with personal care, dysphagia (difficulty swallowing foods or liquids), Type 2 diabetes (is a disease in which your blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 16 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some glucose, or blood sugar, levels are too high), and protein calorie malnutrition (is the state of inadequate intake of food). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #98 was sometimes understood and usually understood others. The MDS indicated Resident #98 had adequate hearing, unclear speech, and highly impaired vision. The MDS indicated Resident #98 had a BIMS score of 05 which indicated severe cognitive impairment and required limited assistance for bathing and extensive assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #98 had weight loss and was not on a physician prescribed weight-loss regimen. Record review of a care plan dated 05/03/23 indicated Resident #98 had potential for pressure ulcer development. Intervention included monitor nutritional status. Serve diet as ordered, monitor intake and record. Record review of a care plan revised on 08/07/23 indicated Resident #98 had potential nutritional problem related to Asperger's Syndrome. Intervention included 06/27/23 RD recommendations: 1. Frozen Nutritional Treat TID meals. Record review of Resident #98's consolidated physician's order dated 06/22/23 indicated Frozen Nutritional Treat with meals for significant weight loss. Record review of Resident #98's Amount Eaten report dated 08/30/23 indicated no meal intake amount for: *08/28/23: 9:00 am, 1:00 pm *08/29/23: 9:00 am, 1:00 pm *08/30/23: 9:00 am, 1:00 pm During an observation on 08/29/23 at 9:06 a.m., revealed Resident #98's breakfast tray had only one bite of ground sausage missing. No frozen treat was noted on Resident #98's tray or bedside table. Resident #98's meal ticket indicated frozen nutritional treat with meals. The observation revealed further that Resident #72's breakfast tray had one glass of milk drank and one bite of oatmeal. During an observation on 08/29/23 at 1:25 p.m., revealed Resident #72 only ate his dessert, and his roommate gave him another dessert. Resident #72 did not eat his 2 chopped beef sandwiches. Resident #98's ate 50-75% of lunch. No frozen treat was noted on Resident #98's tray or bedside table. During an observation on 08/29/23 at 6:36 p.m., revealed Resident #72 only drank his milk for dinner. Resident #98's ate 0-25% for dinner. No frozen treat was noted on Resident #98's tray or bedside table. During an observation on 08/29/23 at 6:38 p.m., at the end of 300 hall, revealed a bucket with ice had frozen treats and house shakes. During an observation on 08/30/23 at 8:56 a.m., revealed Resident #98 did not eat breakfast but drank a house shake. No frozen treat was noted on Resident #98's tray or bedside table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 17 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 08/30/23 at 9:03 a.m., CNA A said Resident #98 normally drank house shakes and today was the first time to hear he was supposed to have frozen treats with his meals. She said dietary was responsible for providing the frozen treats. CNA A said she had not gotten into the facility's electronic charting system and charted Resident #72 or Resident #98's meal intakes for the last 3 days. She said she had not looked at Resident #72 and Resident #98's care plan recently. She said Resident #98 and Resident #72 did not eat much the last three days. CNA A said maybe one day Resident #98 and Resident #72 ate 25-50% of their food. She said she was responsible for documenting meal intake and LVNs ensured it was inputted and correct. CNA A said it was important to document meal intake so the dietician would know if she needed to make changes. She said it was important to follow the care plan intervention to offer frozen treats to Resident #98 to help with weight loss and let the dietician know if the interventions worked. During an interview on 08/30/23 at 2:07 p.m., LVN D said Resident #72 and Resident #98 were being monitored for weight loss. She said both residents were getting prescribed nutritional supplements by the nurses. LVN D said CNAs and LVNs should chart residents meal intakes. She said LVNs should make sure the meal intakes were documented at the end of the shift as the care plan intervention indicated. LVN D said the kitchen placed the house shakes and frozen treats on ice in a bucket on each hall. She said the CNAs should hand the nutrition frozen treats out to each resident. LVN D said the DON looked at the meal intake report to determine which resident needed to be seen by the dietician or dietary manager. She said dietary recommendations on the care plan should be followed to prevent further weight loss and improve nutritional status. LVN D said if recommendations were not followed, or meal intakes not documented residents were at risk for dehydration or illnesses. During an interview on 08/31/23 at 8:20 a.m., LVN C said CNAs were responsible for documenting meal intakes. She said Resident #72 and Resident #98 were being monitored for weight loss. LVN C said Resident #72 normally ate 50% and Resident #98 75-100%. She said LVNs should make sure CNAs were documenting meal intakes. LVN C said it was important to document meal intakes to monitor for change of condition and know if a resident needed a supplement. She said dietary recommendation should be followed to prevent decline, skin breakdown, and improve nutrition. During an interview on 08/31/23 at 9:45 a.m., the DON said CNAs and LVNs should document resident's meal intake in the facility's computer system. She said nursing staff were responsible for providing resident frozen treats per the doctor's orders and meal tickets. The DON said it was important to document meal intake and give dietary recommendations so dietary interventions could be planned, and new interventions developed, or revisions made to the care plan to prevent further weight loss. The DON said all nursing staff had access to resident's care plans on the facility's electronic charting system and should be followed. She said managers should review residents' charts to ensure it was being done and the dietician would also look at the information documented. During an interview on 08/31/23 at 10:41 a.m., the ADM said CNAs should document meal intake amounts. He said nursing staff and dietary were responsible for dietary recommendations. The ADM said it was important to document and follow recommendation, to know if the resident received proper nutrition and prevent further weight loss. He said nursing administration should oversee this process. Record review of a facility Care Planning policy revised 10/24/22 indicated .each resident's comprehensive care plan will describe the following .services that are to be furnished to attain or maintain the resident's highest practicable physical .well-being Record review of a facility Nutrition/Hydration Management policy revised 06/20 indicated .to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 18 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0656 Level of Harm - Minimal harm or potential for actual harm ensure that each resident maintains acceptable parameters of nutritional status .implementing the nutritional/hydration program .a comprehensive care plan is developed .that addresses nutrition/hydration and an individualized .management program based on individualized assessed needs Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 19 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team and the participation of the resident for 1 of 2 residents (Resident #82) reviewed for care plan timing and revision. The facility failed to ensure the IDT were in attendance to Resident #82's care plan meeting. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of Resident #82's face sheet dated 08/30/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (stroke), diabetes mellitus (a group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), and bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #82's annual MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #82 had a BIMS score of 15, indicating his cognition was intact. The MDS did not indicate Resident #82 had any behaviors or refused care. The MDS indicated Resident #82 required extensive assistance with personal hygiene and dressing. Resident #82 required extensive assistance with bed mobility and toileting. Record review of Resident #82's care plan conference dated 08/02/23, indicated Resident #82 and the MDS Coordinator attended the meeting. The care plan conference indicated Resident #82's family did not attend and had n/a marked under RN, nurse aide, food service staff, physician, activity director and social service director. During an interview on 08/28/23 at 3:06 PM, Resident #82 said he had not attended a care plan meeting. Resident #82 said he would have liked to have gone to his care plan meetings. Resident #82 said the staff did not come to his room to have the meeting and he had not received an invitation to attend the care plan meetings. During an interview on 08/30/23 at 08:35 AM, Resident #82 said he did not remember having a care plan meeting in the beginning of the month of August 2023. Resident #82 said he could not recall ever having a care plan meeting. Resident #82 said he would like to be invited and be able to attend so he could know about his care. During an interview on 08/30/23 at 04:50 PM, the ADM said the policy indicated the care plan meeting was held with the IDT which consisted of the MDS Coordinator, dietary, activity director, and social services. The ADM said it was not a complete IDT meeting if only the MDS Coordinator and the resident attended the meeting. During an interview on 08/30/23 at 05:22 PM, the DON said a care plan meeting was conducted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 20 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the IDT which included the social worker, rehab director, dietary, and activities. The DON said she did not consider the IDT care conference meeting if only the MDS Coordinator and the resident attended the meeting. The DON said the MDS Coordinator was responsible for coordinating the meeting with each department. During an interview on 08/31/23 at 09:34 AM with MDS W and Corporate MDS, MDS W said she had the care plan meeting with Resident #82 on 08/02/23 and it was held in his room. MDS W said she probably did not say it was a meeting so Resident #82 probably did not think it was a meeting. The Corporate MDS said when the care plan meeting was held the dietary supervisor was in the hospital, there was not a social worker or activities director. Resident #82 was receiving therapy and when asked how come therapy was not invited, she said she did not know. Record review of the facility's policy Care planning revised October 24, 2022, indicated .To ensure that a comprehensive person-centered Care plan is developed for each resident based on their individual assessed needs .XI The Comprehensive Care Plan must be prepared by the IDT team. The IDT team includes the following individuals: A. The Attending Physician; B. The Resident Assessment Coordinator; C. The Licensed nurse who is responsible for the resident; D. The Dietary Supervisor and/or registered dietician; E. Social Service staff member responsible for the resident; F. The Activity Director, G. Therapist as applicable; H Consultants (as appropriate); J. Certified Nursing Assistants and/or RNAs responsible for the resident's care; K. The resident and/or his/her family or legal representative; L. Other individuals as appropriate or necessary .IV. IDT meeting A. The Facility will invite the resident, if capable, and their family to care plan meetings and use its best effort to schedule care plan meetings at times convenient for the resident and family FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 21 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene were provided for 4 of 6 residents reviewed for ADLs (Resident # 79, Resident #98, Resident #66, Resident #90). Residents Affected - Some 1. The facility failed to ensure Resident #79 received her scheduled bed bath. 2. The facility failed to ensure Resident #98 received his schedule bed baths. 3. The facility failed to ensure Resident #98 was offered to get out of bed. 4. The facility failed to ensure Resident #66 was routinely showered/bathed and shaved. 5. The facility failed to ensure Resident #90 was routinely showered/bathed. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Record review of a face sheet dated 08/30/23 indicated Resident #79 was a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses including Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves.), contracture (reduce joint mobility and restrict activities of daily living) left and right ankle, stiffness in right and left shoulder, and need for assistance with personal care. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. The MDS indicated Resident #79 had minimal difficulty hearing, clear speech, and adequate vision. The MDS indicated Resident #79 had a BIMS score of 11 which indicated moderate cognitive impairment and did not reject care. The MDS indicated Resident #79 required extensive assistance for bed mobility and personal hygiene, and total dependence for dressing, toilet use and bathing. The MDS indicated Resident #79 had limited range of motion bilateral upper and lower extremities. The MDS indicated Resident #79 was always incontinent of urinary and bowel. Record review of a care plan dated 04/06/23 indicated Resident #79 had an ADL self-care performance deficit related to weakness and nerve damage related to Guillain Barre Syndrome. Intervention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 22 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0677 included personal hygiene/oral care required 1 staff dependent participant. Level of Harm - Minimal harm or potential for actual harm Record review of the undated 300 hall shower schedule indicated Resident #79's bath days were day shift Tuesday's, Thursday's, and Saturday's. Residents Affected - Some Record review of Resident #79's shower sheet for the month of August 2023 indicated one bed bath was given on 08/24/23 by CNA A. During an interview and observation on 08/28/23 at 12:27 a.m., Resident #79 said she got a bed bath about every 2 weeks but would like to get one at least once a week. She said she did not have any bed sores and her last bath was earlier in the week by CNA A. Resident #79 was sitting up in bed with slightly oily hair and personal clothing. 2. Record review of a face sheet dated 08/28/23 indicated Resident #98 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), muscle weakness, slowness and poor responsiveness, limitation of activities due to disability, and need for assistance with personal care. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #98 was sometimes understood and usually understood others. The MDS indicated Resident #98 had adequate hearing, unclear speech, and highly impaired vision. The MDS indicated Resident #98 had a BIMS score of 05 which indicated severe cognitive impairment and required limited assistance for bathing and extensive assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #98 had limited range of motion to his upper and lower extremities on one side. The MDS indicated Resident #98's mobility device was a wheelchair. The MDS indicated Resident #98 had an indwelling catheter and always incontinent for bowel continence. Record review of a care plan dated 05/03/23 indicated Resident #98 had an ADL self-care deficit. Interventions included transfers: required 2 staff dependent participation with transfers using mech lift and bathing: required 1 staff participation with bathing. Record review of the undated shower schedule indicated Resident #98 bath days were evening shift Tuesday's, Thursday's, and Saturday's. Record review of Resident #98's shower sheets for August 2023 indicated a bed bath was given on 08/25/23 and 08/28/23 by CNA A. Record review of an ADL report date August 2023 indicated Resident #98 was transferred: * 6am-6pm: 3 out of 29 days * 6pm-6am: 3 out of 29 days During an observation on 08/28/23 at 9:43 a.m., revealed Resident #98 was in bed with a hospital gown on and disheveled hair. During an observation on 08/28/23 at 3:48 p.m., revealed Resident #98 was in bed with a hospital gown on and disheveled hair. There was a recliner in the corner of his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 23 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0677 Level of Harm - Minimal harm or potential for actual harm During an observation on 08/29/23 at 1:25 p.m., revealed Resident #98 was in bed with a hospital gown on and disheveled hair. There was a recliner in the corner of his room. During an observation on 08/29/23 at 8:30 a.m., revealed Resident #98 was in bed with a hospital gown on and disheveled hair. There was a recliner in the corner of his room. Residents Affected - Some During an observation and interview on 08/30/23 at 8:56 a.m., revealed Resident #98 was in bed with a hospital gown on, disheveled hair and nails with brown material underneath them. There was a recliner in the corner of his room. Resident #98 repeatedly said no, no and when asked if he wanted to get out of bed, he said yes. During an interview on 08/30/23 at 9:03 a.m., CNA A said residents should get bed bath or showers per schedule. She said Resident #79 and Resident #98 were scheduled on the day shift. CNA A said bathing was important for residents to controls smells and care for the skin. She said CNAs were responsible and LVNs should make sure they were getting done. CNA A said she did not know why Resident #98 had not been out of the bed more frequently. She said he would need a special chair to get out of bed which he did not have in his room. During an interview on 08/30/23 at 2:07 p.m., LVN D said residents should get bed bath or showers on scheduled days. She said CNAs were responsible and if the resident refused, they should inform the nurse. LVN D said the nurse should make sure resident were getting bed bath or shower when scheduled. She said bathing was important for hygiene and it was the resident's right. During an interview on 08/31/23 at 8:20 a.m., LVN C said bathing occurred dependent on the resident, as needed, and by the schedule. She said CNAs were responsible but if a nurse had time, they should help too. LVN C said LVNs should ensure residents received bathing on schedule or when they wanted. She said bathing was important for infection control, notice skin issues, and hygiene. LVN C said residents should be gotten out of bed when they asked or daily. She said she did not know when the last time Resident #98 had been out of the bed. 3. Record review of Resident #66's face sheet dated 08/30/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident #66's diagnoses included metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), hypertension (high blood pressure), and atrial fibrillation (abnormal heartbeat). Record review of Resident #66's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #66 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS indicated Resident #66 required extensive assistance with bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. The MDS did not indicate Resident #66 refused care. Record review of Resident #66's comprehensive care plan revised on 04/07/21, indicated he had an ADL self-care performance deficit related to recent onset of atrial fibrillation. The care plan intervention indicated Resident #66 required supervision staff participation with bathing. Record review of the facility's shower sheet for hall 300, indicated Resident #66 was scheduled to receive a shower/bath on Monday's, Wednesday's, and Friday's on the day shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 24 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0677 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 08/28/23 at 09:35 AM, Resident #66 said he had not received a shower in over a week. Resident #66 had 1.5 inch facial hair and he said it bothered him at times when he got hot. Resident #66 said the last time they shaved him was when he was provided a shower. Resident #66 said he would like to receive his showers at least 3 times a week. Resident #66 said he did not have any skin issues. Residents Affected - Some Record review of Resident #66's documentation survey report for August 2023, indicated the resident was bathed on 08/07/23, 08/09/23, and 08/11/23. There was no bathing documented from 08/12/23- 08/29/23. During an interview on 08/30/23 at 10:03 AM, Resident #66 said he had not received a shower that week. During an interview on 08/30/23 at 01:49 PM, CNA Y said she usually worked the 300 hall from rooms 316-331 and started at the facility about a month ago. CNA Y said she had not given Resident #66 a bath or shower since she started. C NA Y said Resident #66 was scheduled to receive a shower or bath on 6a-6p shift. CNA Y said CNA A helped her with providing Resident #66'showers. CNA A said not providing a resident with a shower/bath could be considered neglect. CNA A said the CNAs were responsible for ensuring the baths/showers were provided. During an interview on 08/30/23 at 01:49 PM, CNA A said the last time she provided Resident #66 with a shower was about 2 to 2.5 weeks ago. CNA A said the CNA for that hall was responsible for providing the showers to Resident #66. CNA A said she used to be the shower aide but now worked as a CNA on the floor for rooms 300 to 315 and had not worked with Resident #66 since. CNA A said Resident #66 liked his showers and never refused them. CNA A said residents were at risk for skin issues by not being routinely showered/bathed. During an interview on 08/30/23 at 2:02 PM, LVN V said Resident #66 did not refuse his showers. LVN V said shower sheets were supposed to be completed by the CNA who provided the showers. LVN V said she was unaware Resident #66 had not received his showers as desired. 4. Record review of Resident #90's face sheet dated 08/30/23, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #90's diagnoses included anxiety (feeling of fear, dread, and uneasiness), anemia (condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), need for assistance with personal care, and end stage renal disease (condition in which the kidneys lose the ability to remove waste and balance fluids.). Record review of Resident #90's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS indicated Resident #90 had a BIMS score of 11, indicating she had moderately impaired cognition. The MDS did not indicate Resident #90 had behaviors or refused care. The MDS indicated Resident #90 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #90 required total care with transfers, locomotion of the unit, and bathing. Record review of Resident #90's undated comprehensive care plan indicated she had an ADL self-care performance deficit. The care plan intervention indicated Resident #90 required one staff participation with bathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 25 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the facility's shower sheet for hall 300, indicated Resident #90 was scheduled to receive a shower/bath on Tuesday's, Thursday's, and Saturday's on the evening shift. During an observation and interview on 08/29/23 at 11:47 AM, Resident #90's hair was greasy and she said her last shower was a couple of months ago. Resident #90 said she would like to receive her showers/baths at least once a week. Resident #90 said not receiving her showers as desired made her feel unclean. Record review of Resident #90's shower sheets for the last months July 1, 2023- August 29, 2023, indicated Resident #90 received bed baths on 7/1/23, 7/6/23, 7/11/23, and 7/20/23. No shower sheets were provided for the month of August 2023. During an interview on 08/30/23 at 10:32 AM, ADON O said she provided all the shower sheets that were available for Resident #90 and there were no shower sheets to provide for the month of August 2023. Record review of Resident #90's documentation survey report for the month of July 2023 indicated Resident #90 was bathed on 07/19/23, 07/22/23, and 07/27/23. Record review of Resident #90's documentation survey report for the month of August 2023 indicated Resident #90 was bathed on 08/02/23, 08/05/23, 08/07/23, and 08/11/23. There was no bathing documented from 08/12/23- 08/29/23. During an interview on 08/30/23 at 2:02 PM, LVN V said Resident #90 did not refuse her showers. LVN V said if a resident was scheduled at night, they were more than likely not getting them. LVN V said shower sheets were supposed to be completed by the CNA who provided the showers. LVN V said she was unaware Resident #90 had not received her showers as desired. During an interview on 08/30/23 at 03:36 PM, CNA X said she worked the 6p-6a shift. CNA A said Resident #90 refused her showers as she screams and hollers every time they got her in the shower. CNA X said she provided a bed bath to Resident #90 on Sunday , 08/27/23, but did not fill out a shower sheet or document in the EMR because, she said, had a lot on my mind. CNA X said if it was not documented it was given then it was considered not done. CNA X said it was the CNAs responsibility to ensure documentation was completed. CNA X said by not providing the showers/baths could cause skin issues. During an interview on 0830/23 at 08:45 AM, Resident #90 said CNA X did not provide her with a bed bath. Resident #90 said she did not refuse her showers. During an interview on 08/30/23 at 04:19 PM, ADON O said she expected bathing to be provided at least once a week as per the facility's policy. ADON O said they did have a shower schedule for 3 times a week, but their policy only required once a week. ADON O said the staff sometimes documented in the point click care system (electronic documentation system) or on a shower sheet. ADON O said it was the charge nurse's responsibility to ensure the shower sheets were completed. ADON O said the resident not receiving their showers as desired could lead to skin disruptions. During an interview on 08/30/23 at 04:50 PM, the ADM said he expected showers/baths be provided as needed per the resident's preference. The ADM said CNAs and the charge nurses were responsible for ensuring the showers/baths were provided. The ADM said not bathing the resident routinely could cause (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 26 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0677 residents to be dirty, skin breakdown and infection. Level of Harm - Minimal harm or potential for actual harm During an interview on 08/31/23 at 9:45 a.m., the DON said CNAs should document bathing on the shower sheet and facility computer system. She LVNs should ensure bathing happened at least once a week. The DON said the managers should review ADL sheets and shower sheets to ensure resident were receiving baths. She said the administrative nurses should review ADL sheets and shower sheets daily. The DON said bathing was important for hygiene, cleanliness, and skin care. She said residents should be encouraged to get out of bed often. The DON said CNAs and LVNs should encourage residents to get out of bed at least daily. She said even if a resident was on isolation, like Resident #98, he should still be gotten out of bed when he wanted to. Residents Affected - Some During an interview on 08/31/23 at 10:41 a.m., the ADM said resident should be bathed as needed and when requested by the CNAs. He said it was important for infection control and identifying skin breakdown. The ADM said charge nurses and mangers should ensure bathing happened when requested and as needed. Record review of the undated facility Showering a Resident policy indicated .a shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors .residents are offered a shower at a minimum of once weekly and given per resident request Record review of a facility Resident Rights-Accommodation of Needs policy dated 08/20 indicated .to ensure that the facility provides an .services that meet residents' individual needs .the facility's environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being .facility staff will assist resident in achieving goals FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 27 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 - Some 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** 2. Record review of a face sheet dated 08/30/23 indicated Resident #79 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves.), contracture (reduce joint mobility and restrict activities of daily living) left and right ankle, stiffness in right and left shoulder, and need for assistance with personal care. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. The MDS indicated Resident #79 had minimal difficulty hearing, clear speech, and adequate vision. The MDS indicated Resident #79 had a BIMS score of 11 which indicated moderate cognitive impairment and did not reject care. The MDS indicated Resident #79 required extensive assistance for bed mobility and personal hygiene, and total dependence for dressing, toilet use and bathing. The MDS indicated Resident #79 had limited range of motion bilateral (both) upper and lower extremities. The MDS indicated Resident #79 was always incontinent of urinary and bowel. Record review of a care plan dated 04/06/23 indicated Resident #79 had an ADL self-care performance deficit related to weakness and nerve damage related to Guillain Barre Syndrome. Intervention included toilet use required 1 staff extensive to dependent participation for toileting. Record review of a care plan dated 04/06/23 indicated Resident #79 had bowel and bladder incontinence. Intervention included check the resident as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. During an interview on 08/28/23 at 12:27 p.m., Resident #79 said she was normally changed at 9:30 a.m. and 3:30 p.m. She said yesterday (08/27/23) she was changed at 4:30 p.m. and not changed again until 5:30 a.m. by CNA E. Resident #79 said when she pushed the call light to be changed, staff made excuses why they could not change you. Resident #79 said CNAs did not make rounds every 2 hours to see if we needed to be changed. She said she was changed around 9:30 a.m. and was currently wet. Resident #79 said she took a water pill in the morning, so she needed to be changed more often. During an interview on 08/29/23 at 8:53 a.m., Resident #79 said the last time she was changed was at 8:00 p.m. (08/28/23). She said she did not know who her CNA was today, and she had soaked through her brief and drawsheet. During an interview and observation on 08/29/23 at 10:41 a.m., Resident #79 said she still had not been changed. Resident #79's drawsheet she was sitting on was wet with urine. During an interview on 08/29/23 at 6:12 p.m., Resident #79 said she had been changed last at 3:30 p.m. 3. Record review of a face sheet dated 08/30/23 indicated Resident #89 was a [AGE] year-old female and admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia (is a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), limitation of activities due to disability, and need for assistance with personal care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 28 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 - Some Record review of a quarterly MDS assessment dated [DATE] indicated Resident #89 was understood and understood others. The MDS indicated Resident #89 had clear speech, adequate hearing, and adequate vision. The MDS indicated Resident #89 had a BIMS score of 10 which indicated moderately impaired cognition and did not reject care. The MDS indicated Resident #89 required limited assistance for bed mobility and personal hygiene, extensive assistance for dressing, total dependence for toilet use, bathing, and transfers. The MDS indicated Resident #89 was always incontinent of urinary and bowel. Record review of a care plan dated 09/08/22 indicated Resident #89 had ADL self-care performance deficit. Intervention included toilet use required 2 staff participation to use toilet, transfers, and bed mobility. Record review of an in-service training report, Incontinent care, dated 08/09/23 at 7:00 p.m. by the DON indicated .are residents on the night shift being changed timely when they have incontinent episodes? . every resident should be checked for incontinent episodes . rounds should be made every 2 hours .check the resident and the linen .change as needed . assist residents with toileting .keep the call light in reach at all times . 12 staff members signed the training. During an interview on 08/28/23 at 11:25 a.m., Resident #89 said she was changed one-time on night shift by CNA E. During an interview on 08/29/23 at 6:15 p.m., Resident #89 said she was changed one-time on night shift at 5:15 a.m. by CNA E. During an interview on 08/30/23 at 9:03 a.m., CNA A said she tried to make rounds every 2 hours to check resident for incontinent episodes. She said on Mondays and Tuesdays she did not get to work until 7:30 am or 8:00 am so her first rounds were after breakfast. CNA A said Resident #79 was extremely wet on 08/29/23 when she changed her. She said Resident #79 told her she had not been changed all night. CNA A said she had started her shift and resident had been wet. She said Resident #79 and Resident #89 had complained about not getting changed at night and I told them to report it to upper management. CNA A said timely incontinent care was important to prevent skin breakdown and odors. During an interview on 08/30/23 at 2:07 p.m., LVN D said resident should be changed as needed and every 2 hours. She said CNAs and LVNs were responsible for incontinent care. LVN D said LVNs should ensure resident were getting changed timely. She said it was important to prevent skin breakdown, infection, and pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin). During an interview on 08/30/23 at 5:34 p.m., CNA E said she did work Sunday (08/27/23) and Monday (08/28/23) night shift on the 300 hall. She said she provided incontinent care every 2 hours, as needed, or when the resident called. CNA E said she did her last rounds at 4:30 a.m. She said timely incontinent care was important to prevent skin irritation and breakdown. During an interview on 08/31/23 at 8:20 a.m., LVN C said resident should be changed every 2 hours and as needed. She said CNAs and LVNs were responsible for changing residents. LVN C said LVNs should ensure CNAs changed residents timely. She said timely changing was important for infection control, notice skin issues, hygiene, and dignity. During an interview on 08/31/23 at 9:45 a.m., the DON said resident should be rounded on every 2 hours and as needed to check for incontinent episodes. She said CNAs and LVNs were responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 29 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 - Some timely incontinent care. The DON said LVNs should ensure resident were changed timely. She said managers should oversee the process by checking ADL sheets and rounding daily. The DON said incontinence care was important for hygiene, cleanliness, and skin care. During an interview on 08/31/23 at 10:41 a.m., the ADM said resident should be changed as needed and when requested by the CNAs. He said it was important for infection control and identifying skin breakdown. The ADM said charge nurses and mangers should ensure timely incontinent care happened when requested and as needed. Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 3 of 4 resident (Resident #5, #79, and #89) reviewed for incontinence and urinary catheters. The facility failed to ensure Resident #5 had a physician's order for her indwelling urinary catheter with appropriate diagnosis for use. The facility failed to provide timely incontinence care to Resident #79 and Resident #89. These failures could place residents at risk for not receiving appropriate care, infections, skin breakdown and decreased quality of life. Findings included: 1. Record review of Resident #5's face sheet dated 08/30/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (memory loss), neuromuscular dysfunction of bladder (bladder dysfunction caused by nervous system conditions), diabetes mellitus (a group of diseases that result in too much sugar in the blood) and essential hypertension (high blood pressure). Record review of Resident #5's order summary report dated 08/30/23, did not indicate resident had an order for her indwelling urinary catheter. Record review of Resident #5's comprehensive care plan revised on 03/24/23, indicated she had an indwelling catheter related to neurogenic bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition). The care plan interventions included to position catheter bag and tubing below the level of the bladder. Record review of Resident #5's Admission/readmission Evaluation dated 07/26/23, indicated Resident #5 had a 16 French 10ml catheter. Record review of Resident #5's annual MDS assessment dated [DATE], indicated Resident #5 had unclear speech, was usually understood, and usually understood others. The MDS indicated Resident #5 had a BIMS score of 5, which indicated her cognition was severely impaired. The MDS indicated Resident #5 required extensive assistance with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #5 had an indwelling catheter. During an observation on 08/28/23 at 10:58 AM, Resident #5 was lying in her bed. Resident #5 had her foley catheter hanging on the right side of the bed and was covered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 30 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 - Some During an interview on 08/30/23 at 4:19 PM, ADON O said if a resident had a foley catheter then they should have an order for care and maintenance. ADON O said the nurse was responsible for ensuring the order for the foley catheter was placed in the resident's EMR. During an interview on 08/30/23 at 04:50 PM, the Administrator said he expected a resident that had a foley catheter to have an order in place to provide care. The Administrator said not having an order could cause an adverse reaction. The Administrator said the charge nurse was responsible for ensuring the order for the foley catheter was in place. During an interview on 08/30/23 at 05:22 PM, the DON said she expected a resident who had a foley catheter to have an order in place for care. The DON said the nurses were responsible for ensuring the resident had an order in place. The DON said the administrative nurses reviewed orders on any new admissions, readmissions or if there was a change. During an interview on 08/31/23 at 08:48 AM, LVN CC said Resident #5 should have had an order for her foley catheter indicating the reason for the catheter use and catheter size. LVN CC said she was the nurse who readmitted Resident #5 on 07/26/23 and Resident #5 had a catheter upon admission. LVN CC said she must have missed inputting the order for Resident #5's catheter. LVN CC said she was the person responsible for ensuring Resident #5 had an order for her catheter. LVN CC said Resident #5 not having an order for her catheter with appropriate diagnoses could have caused her to have a UTI. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 31 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0692 Provide enough food/fluids to maintain a resident's health. 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 residents were offered sufficient fluid intake to maintain proper hydration and health for 3 of 4 resident (Resident #23, Resident #79, Resident #98) reviewed for hydration. Residents Affected - Few The facility failed to ensure Resident #23, and Resident #79 received adequate hydration. The facility failed to ensure Resident #98 received thickened liquid for hydration between meals. The facility failed to implement the care plan intervention for Resident #98 to receive his Frozen Nutritional Treats with meals. These failures could place residents at risk for dehydration, electrolyte imbalance, and infections. Findings included: 1. Record review of a face sheet dated 08/30/23 indicated Resident #23 was [AGE] year-old female and admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), need for assistance with personal care, and abnormal weight loss. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated Resident #23 had adequate hearing, clear speech, and impaired vision. The MDS indicated Resident #23 had a BIMS score of 15 which indicated intact cognition and only required supervision for dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #23 was always continent for urinary and bowel. Record review of a care plan dated 06/29/21 indicated Resident #23 had chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Intervention included give supplements if needed to maintain adequate nutrition. Encourage good fluid intake. Record review of a care plan with revision date of 06/19/23 indicated Resident #23 had an ADL self-care performance deficit related to impaired vision. Resident #23 was able to do most ADLs with supervision or setup assist. Intervention included needs set up for meals. Record review of Resident #23's Comprehensive Metabolic Panel (is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working) dated 08/11/23 indicated Chloride (is a mineral that helps maintain the acid-base balance in your body.) was 110 which was elevated. Record review of Medline Plus [Internet]. Bethesda (MD): National Library of Medicine (US); (April 04,2022), www.medlineplus.gov/lab-tests/chloride-blood-test was accessed 08/31/23 which indicated .Chloride is a mineral that helps maintain the acid-base balance in your body .normal range 96-109 .high levels of chloride may be a sign of: Dehydration. Kidney disease. Metabolic acidosis, a condition in which you have too much acid in your blood . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 32 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/28/23 at 10:04 a.m., Resident #23 said the facility did not pass ice and water regularly. She said she had to get water out of her bathroom sink and at times you did not get the drink you ordered for meals. During an interview on 08/29/23 at 8:41 a.m., Resident #23 said CNA A filled her water cup yesterday (08/28/23) before she left for the day around 6:30 p.m. She said that was the only time it was filled. 2. Record review of a face sheet dated 08/30/23 indicated Resident #79 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves.), contracture (reduce joint mobility and restrict activities of daily living) left and right ankle, stiffness in right and left shoulder, and need for assistance with personal care. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. The MDS indicated Resident #79 had minimal difficulty hearing, clear speech, and adequate vision. The MDS indicated Resident #79 had a BIMS score of 11 which indicated moderate cognitive impairment and did not reject care. The MDS indicated Resident #79 required extensive assistance for bed mobility and personal hygiene, and total dependence for dressing, toilet use and bathing. The MDS indicated Resident #79 had limited range of motion bilateral (both) upper and lower extremities. The MDS indicated Resident #79 was always incontinent of urinary and bowel. Record review of a care plan dated 04/06/23 indicated Resident #79 had an ADL self-care performance deficit related to weakness and nerve damage related to Guillain Barre Syndrome. Intervention included 1 staff extensive participation for meals. Record review of Resident #79's CMP dated 03/29/23 indicated normal lab values. No recent lab work available to review. During an interview on 08/28/23 at 12:27 p.m., Resident #79 said the facility did not pass out ice and water enough. She said staff probably passes ice and water once a shift. During an interview on 08/29/23 at 2:52 p.m., Resident #79 said she got fresh ice and water today at 2:45 p.m. before LVN C left for the day. She said LVN C did not normally pass ice and water out. 3. Record review of a face sheet dated 08/28/23 indicated Resident #98 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), muscle weakness, slowness and poor responsiveness, limitation of activities due to disability, retention of urine, need for assistance with personal care, dysphagia (difficulty swallowing foods or liquids), Type 2 diabetes (is a disease in which your blood glucose, or blood sugar, levels are too high), and protein calorie malnutrition (is the state of inadequate intake of food). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #98 was sometimes understood and usually understood others. The MDS indicated Resident #98 had adequate hearing, unclear speech, and highly impaired vision. The MDS indicated Resident #98 had a BIMS score of 05 which indicated severe cognitive impairment and required limited assistance for bathing and extensive assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #98 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 33 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0692 an indwelling catheter and always incontinent for bowel continence. Level of Harm - Minimal harm or potential for actual harm Record review of a care plan dated 05/03/23 indicated Resident #98 had an ADL self-care deficit. Interventions included 1 staff participation to eat. Residents Affected - Few Record review of a care plan dated 08/07/23 indicated Resident #98 had urinary tract infection. Intervention included encourage adequate fluid intake. Record review of a care plan revised on 08/07/23 indicated Resident #98 had potential nutritional problem related to Asperger's Syndrome. Intervention included 06/27/23 RD recommendations: 1. Frozen Nutritional Treat TID meals. Record review of Resident #98's CMP dated 05/25/23 indicated all electrolytes within normal ranges except Creatinine (is a blood test used to check how well your kidneys are filtering your blood) was 1.4. No recent lab work available to review. Record review of Mount [NAME] Creatinine blood test (last reviewed 07/21/21), www.mountsinai.org/health, was accessed on 08/31/23 which indicated .normal range 0.6-1.3 .high creatinine level may be a sign that the kidneys are not working like they should . Record review of Resident #98's urinalysis (is a test of your urine. It is often done to check for a urinary tract infection, kidney problems, or diabetes) dated 08/28/23 indicated color (yellow-dark yellow): dark yellow urine (may indicate that a person is mildly dehydrated), clarity (normal range is clear): turbid (cloudy urine possible cause dehydration and infection), protein (normal range is negative: 2 plus (protein in your urine possible causes urinary tract infections, certain infection or illness, dehydration, stress). Record review of Resident #98's weights indicated on 07/03/2023, the resident weighed 130.1 lbs. On 08/01/2023, the resident weighed 127 pounds which was a -2.38 % Loss. During an observation and interview on 08/28/23 at 3:48 p.m., Resident #98 was sitting up in bed with dry, peeling lips and no hydration on bedside tray. Attempted to interview Resident #98 but unable understand because he was soft spoken and mumbled. Discontinued interview because Resident #98 started becoming agitated. During an observation on 08/28/23 at 9:43 a.m.-1:02 p.m. and 2:33 p.m. -4:00 p.m., no ice water was passed to the residents. During an observation on 08/29/23 at 8:30 a.m., Resident #98 had a full cup of red liquid from his breakfast on the bedside table. During an observation on 08/29/23 at 9:06 a.m., revealed Resident #98's breakfast tray had only one bite of ground sausage missing. No frozen treat was noted on Resident #98's tray or bedside table. Resident #98's meal ticket indicated frozen nutritional treat with meals. During an observation on 08/29/23 at 10:34 a.m., Resident #98 was asleep with dry lips and red stained sheet. No cup noted on bedside tray. During an observation on 08/29/23 at 8:56 a.m., Resident #98 had dry lips and drank about 4 oz of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 34 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0692 strawberry house shake. Level of Harm - Minimal harm or potential for actual harm During an observation on 08/29/23 at 6:36 p.m., revealed Resident #98's ate 0-25% for dinner. No frozen treat was noted on Resident #98's tray or bedside table. Residents Affected - Few During an interview on 08/30/23 at 9:03 a.m., CNA A said Resident #98 required thickened liquid for hydration. She said dietary made the drinks, but the CNAs were responsible for giving it to the resident. CNA A said hydration was passed out once yesterday (08/29/23). She said hydration was important to prevent urinary tract infections, dehydration, and dry skin. CNA A said Resident #98 normally drank house shakes and today was the first time to hear he was supposed to have frozen treats with his meals. She said dietary was responsible for providing the frozen treats. She said it was important to follow the care plan intervention to offer frozen treats to Resident #98 to help with weight loss and let the dietician know if the interventions worked. During an interview on 08/30/23 at 2:07 p.m., LVN D said residents should be provided hydration every 2 hours or when they asked. She said she felt resident were getting proper hydration. LVN D said all staff were responsible to provide hydration to residents. She said proper hydration was important to prevent dehydration. LVN D said LVNs should ensure residents received thickened liquids only if ordered and the CNAs should give it to the resident to drink. LVN D said Resident #98 were being monitored for weight loss. She said Resident #98 was getting a prescribed nutritional supplement by the nurses. LVN D said the kitchen placed the house shakes and frozen treats on ice in a bucket on each hall. She said the CNAs should hand the nutrition frozen treats out to each resident. During an interview on 08/31/23 at 8:20 a.m., LVN C said hydration should be provided to resident twice a shift and as needed. She said CNAs were responsible for passing it out and LVNs should ensure it happened twice a shift. LVN C said hydration was important for a resident's well-being, skin, and keep their immune system up. She said aides should provide Resident #98 his thickened liquid between meals. LVN C said she was responsible for ensuring aides only offered him thickened liquids. During an interview on 08/31/23 at 9:45 a.m., the DON said all nursing staff should provide resident hydration in the morning, afternoon, and at bedtime. She said managers should make daily rounds to ensure hydration was provided to residents. She said nursing staff were responsible for providing resident frozen treats per the doctor's orders and meal tickets. The DON said it was important to give dietary recommendations so dietary interventions could be planned, and new interventions developed, or revisions made to the care plan to prevent further weight loss. The DON said hydration was important to a resident's health and prevent adverse effects. She said dietary provided the thickened hydration but CNAs and LVNs should offer it to the resident 3 times a day. During an interview on 08/31/23 at 10:41 a.m., the ADM said resident should receive hydration as needed and when indicated. He said staff should check resident hydration status every 2 hours. He said nursing staff and dietary were responsible for dietary recommendations. The ADM said it was important to document and follow recommendation, to know if the resident received proper nutrition and prevent further weight loss. He said nursing administration should oversee this process. The ADM said CNAs were responsible for providing hydration and the charge nurse and nursing administration should ensure it happened. He said proper hydration prevented dehydration. Record review of a facility Nutrition/Hydration Management policy revised on 06/20 indicated .to ensure that each resident maintains acceptable parameters of nutritional status .developing an individual nutrition/hydration program based on individual assessed needs .ongoing assessment, monitoring, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 35 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0692 and evaluation of the effectiveness of the nutrition/hydration program .the goal of any nutrition/hydration management process is to improve quality of life . 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: 675133 If continuation sheet Page 36 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 Provide safe and appropriate respiratory care 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 that respiratory care was provided consistent with professional standards of practice for 7 of 35 residents reviewed for respiratory care. (Resident #4, Resident #26, Resident #34, Resident #56, Resident #67, Resident #73, and Resident #75). Residents Affected - Some 1. The facility failed to ensure oxygen concentrator filters were free of gray fuzz, hair-like and dust-like particles for Resident #4, Resident #26, Resident #34, and Resident #73. 2. The facility failed to ensure Resident #75's oxygen concentrator was free of gray fuzz and dust-like particles in the slatted vent on the back of the oxygen concentrator. 3. The facility did not ensure oxygen concentrator filters were free from brown like substances for Resident #56 and Resident #67. 4. The facility failed to ensure Resident #26's oxygen tubing was changed weekly per physician orders. These failures could place residents at risk of respiratory infections. Findings included: 1. Record review of Resident #4's face sheet dated 8/30/23 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #4 had diagnoses of COPD (chronic obstructive pulmonary disease -constriction of the airways and difficulty or discomfort in breathing), hypertension (high blood pressure), diabetes (high blood sugar), and weakness. Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed she was understood and understood others. Resident #4 had a BIMS of 12, which indicated she had moderate cognitive impairment. Resident #4 required limited assistance of 1 person for most ADLs. Resident #4 had shortness of breath when lying flat. Record review of Resident #4's undated care plan revealed she had oxygen therapy at 2 LPM by NC for COPD. Record review of Resident #4's Order Summary Report dated 8/30/23 revealed an order to change respiratory tubing, mask, bottled water, clean filter every seven days on Sunday night shift. There was an order to clean oxygen concentrator filter with soap and water every week on Sunday night shift. Record review of Resident #4's NAR dated 8/01/23-8/31/23 revealed the change respiratory tubing, mask, bottled water, clean filter every seven days on Sunday night shift was documented completed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 37 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 - Minimal harm or potential for actual harm Residents Affected - Some 8/06/23, 8/13/23, 8/20/23, and 8/27/23. Resident #4's NAR also revealed the clean oxygen concentrator filter with soap and water every week on Sunday night shift was documented completed on 8/06/23, 8/13/23, 8/20/23, and 8/27/23. During an observation and interview on 8/28/23 at 9:31 AM, Resident #4 was sitting up in bed with her oxygen at 2 LPM by NC. The oxygen concentrator filter was covered in gray fuzz and dust-like particles. Resident #4 said the facility changes the oxygen tubing every week, but she said she did not know when they cleaned the filter on the oxygen concentrator. During an observation on 8/29/23 at 9:32 AM revealed Resident #4 was sitting in her wheelchair at her bedside wearing her oxygen at 2 LPM by NC. Resident #4's oxygen concentrator continued to have a filter covered in gray fuzz and dust-like particles. 2. Record review of Resident #26's face sheet dated 8/30/23 revealed he was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #26 had diagnoses of history of sepsis (life threating infection), COPD, hypertension, history of a cerebral infarction (stroke-lack of adequate blood supply to the brain cells causing parts of the brain to die), heart failure, and weakness. Record review of Resident #26's quarterly MDS assessment dated [DATE] revealed he had unclear speech, was sometimes able to make himself understood, but he understood others. Resident #26 had a BIMS of 8, which indicated he had moderate cognitive impairment. Resident #26 required total assistance of 1 person for all ADLs. Record review of Resident #26's undated care plan revealed he had COPD and altered respiratory status/difficulty breathing related to respiratory failure. Record review of Resident #26's Order Summary Report dated 8/30/23 revealed an order to clean oxygen concentrator filter with soap and water every week on Sunday night shift. There was an order for oxygen at 2-5 LPM by NC every shift. There was also an order to change oxygen tubing every week on Sunday night shifts and nurse to date and initial. Record review of Resident #26's NAR dated 8/01/23-8/31/23 revealed the change oxygen tubing every week on Sunday night shift was documented completed on 8/06/23, 8/13/23, 8/20/23, and 8/27/23. Resident #26's NAR also revealed the clean oxygen concentrator filter with soap and water every week on Sunday night shift was documented completed on 8/06/23, 8/13/23, 8/20/23, and 8/27/23. During an observation on 8/28/23 at 11:24 AM, Resident #26 was lying in bed with the head of the bed elevated, with his oxygen on at 2 LPM by NC. Resident #26's oxygen tubing was dated 8/14/23 and the oxygen concentrator filter was covered in gray fuzz and dust-like particles. During an observation on 8/29/23 at 9:41AM revealed Resident #26 was lying in bed wearing his oxygen at 2 LPM by NC. Resident #26's oxygen tubing continued to be dated 8/14/23 and the oxygen concentrator continued to have a filter covered in gray fuzz and dust-like particles. 3. Record review of Resident #34's face sheet dated 8/29/23 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #34 had diagnoses of shortness of breath, heart failure, reduced mobility, hypertension, diabetes, weakness, dependent on supplemental oxygen, obstructive sleep apnea (blockage in airway keeps air from moving through the windpipe during sleep), and chronic bronchitis (long-term inflammation of the airways). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 38 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 - Minimal harm or potential for actual harm Record review of Resident #34's quarterly MDS assessment, dated 7/07/23, indicated Resident #34 had clear speech and was understood by staff. The MDS indicated Resident #34 was able to understand others. The MDS indicated Resident #34 had a BIMS of 12, which indicated moderate cognitive function impairment. The MDS revealed Resident #34 required extensive assistance of 1-2 persons for most ADLs. Resident #34 was receiving oxygen therapy. Residents Affected - Some Record review of Resident #34's undated care plan revealed she received oxygen therapy related to respiratory failure and chronic bronchitis and she had altered respiratory status/difficulty breathing related to sleep apnea. Record review of Resident #34's Order Summary Report dated 8/30/23 revealed an order to clean oxygen concentrator filter with soap and water every week on Sunday night shift. There was an order for oxygen at 2-5 LPM by NC to keep oxygen saturation greater than 90%. Record review of Resident #34's NAR dated 8/01/23-8/31/23 revealed the clean oxygen concentrator filter with soap and water every week on Sunday night shift was documented completed on 8/06/23, 8/13/23, 8/20/23, and 8/27/23. During an observation and interview on 8/28/23 at 10:15 AM, Resident #34 was sitting up in bed with her oxygen at 4 LPM by NC. The oxygen concentrator filter was covered in gray fuzz, hair-like, and dust-like particles. Resident #34 said the facility usually changed the oxygen tubing every week, but she said she did not know when they cleaned the filter on the oxygen concentrator. During an observation on 8/29/23 at 9:35 AM revealed Resident #34 was sitting up in bed wearing her oxygen. Resident #34's oxygen concentrator continued to have a filter covered in gray fuzz, hair-like, and dust-like particles. 4. Record review of Resident #56's face sheet, dated 8/28/23, indicated Resident #56 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), Shortness of breath (the uncomfortable sensation of not getting enough air to breathe), and high blood pressure. Record review of Resident #56's quarterly MDS assessment, dated 6/14/23, indicated Resident #56 was understood and usually understood others. Resident #56's BIMs score was 08, which indicated he was cognitively moderately impaired. Resident #56 required total assist with toileting, dressing, bathing, limited assist with bed mobility, personal hygiene, and eating. The MDS did indicate Resident #56 wore oxygen during the last 7 day look back period. Record review of Resident #56's physician orders, dated 8/04/23 revealed clean oxygen concentrators filters with soap and water every week on Sunday nights. Record review of Resident #56's comprehensive care plan, dated 4/15/21, indicated Resident #56 had altered respiratory status, difficulty breathing related to chronic respiratory failure and COPD. The interventions of the care plan were for staff to apply oxygen as ordered, monitor for signs and symptoms of respiratory distress, and report any changes in decline to the physician. During an observation on 8/28/23 at 9:32 AM, Resident #56 was in his bed receiving oxygen at 2 liters per minute via nasal cannula. Resident #56's oxygen concentrator filter had brown like substance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 39 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 on it. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 8/30/23 at 2:50 PM, LVN T saw Resident #56's concentrator filter and said it was dirty. She said night shift were supposed to clean on Sunday nights. LVN T said she would clean the filter. LVN T said failure to have clean oxygen concentrator filters could lead to infection control issues. Residents Affected - Some Record review of Resident #56's MAR dated August 2023 revealed initials in the box indicating his oxygen concentrator filters were cleaned as ordered. 5. Record review of Resident #67's face sheet, dated 8/10/23, indicated Resident #67 was an [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), Shortness of breath (the uncomfortable sensation of not getting enough air to breathe), and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily living). Record review of Resident #67's quarterly MDS assessment, dated 8/09/23, indicated Resident #67 was understood and understood others. Resident #67's BIMs score was 12, which indicated he was cognitively moderately impaired. Resident #67 required extensive assist with toileting, bathing, transfer, dressing, bed mobility, limited assist with personal hygiene, and set up for eating. The MDS did indicate Resident #67 wore oxygen during the last 7 day look back period. Record review of Resident #67's physician orders, dated 8/04/23 revealed clean oxygen concentrator filters with soap and water every week on Sunday nights. Record review of Resident #67's comprehensive care plan, dated 4/14/21 indicated Resident #67 had oxygen therapy related to his shortness of breath. The interventions of the care plan were for staff to monitor for signs and symptoms of respiratory distress and report any changes in decline to the physician. During an observation on 8/28/23 at 10:04 AM, Resident #67's oxygen concentrator had brown material on the filter. During an observation and interview on 8/29/23 at 6:00 PM, Resident #67's sitting on side of his bed with oxygen on at 2 liters via nasal cannula. His oxygen concentrator filter remained with brown material. Resident #67 did not remember if staff cleaned concentrator filters or not. During an observation and interview on 8/29/23 at 6:19 PM, LVN P said she was responsible as the 6p-6a nurse to change and date oxygen tubing and clean concentrator filters. She said she cleaned filters on Saturday night going into Sunday. She said she worked last Sunday (8/20/23). She said she cleaned the concentrators on her assigned hall with a wet cloth and wiped the filters. LVN P said Resident #67 did not have a filter on his concentrator. Surveyor asked LVN P to open the small box located on the side of Resident #67's concentrator. LVN P opened the box and saw the filter which contained brown like substances and said it was filthy. LVN P said she did not clean Resident #67's oxygen concentrator filter because she was not aware he had a filter. She said failure to keep filters clean could lead to respiratory issues. Record review of Resident #67's MAR dated August 2023 revealed initials in the box indicating his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 40 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 oxygen concentrator filters were cleaned as ordered. Level of Harm - Minimal harm or potential for actual harm 6. Record review of Resident #73's face sheet dated 8/29/23 revealed he was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #73 had diagnoses of COPD, shortness of breath, respiratory failure, weakness, heart failure, and pulmonary fibrosis (lung disease where lung tissue becomes damaged and scarred, thickened and stiff making it harder for lungs to work properly). Residents Affected - Some Record review of Resident #73's annual MDS assessment dated [DATE] revealed he was understood and understood others. Resident #73 had a BIMS of 15, which indicated he was cognitively intact. Resident #73 required limited to extensive assistance of 1 person for most ADLs. Resident #73 had shortness of breath when lying flat and received oxygen therapy. Record review of Resident #73's undated care plan revealed he had shortness of breath, altered respiratory status/difficulty breathing related to respiratory failure and COPD. Record review of Resident #73's Order Summary Report dated 8/30/23 revealed an order to change oxygen tubing every week on Sunday night shift, but there was no order to clean oxygen concentrator filter. Record review of Resident #73's NAR dated 8/01/23-8/31/23 revealed there was no order to clean oxygen concentrator filter. During an observation and interview on 8/28/23 at 10:28 AM, Resident #73 was lying in bed with his oxygen on at 4 LPM by NC. The oxygen concentrator filter was heavily covered in gray fuzz, hair-like and dust-like particles. Resident #73 said the facility changes the oxygen tubing every week, but he said he did not know when they cleaned the filter on the oxygen concentrator. During an observation on 8/29/23 at 9:34 AM revealed Resident #73 was sitting on side of bed wearing his oxygen. Resident #73's oxygen concentrator continued to have a filter heavily covered in gray fuzz, hair-like and dust-like particles. 7. Record review of Resident #75's face sheet dated 8/30/23 revealed he was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #75 had diagnoses of shortness of breath, hypertension, respiratory failure, obstructive sleep apnea, and weakness. Record review of Resident #75's quarterly MDS assessment dated [DATE] revealed he was understood and understood others. Resident #75 had a BIMS of 15, which indicated he was cognitively intact. Resident #75 required extensive to total assistance of 1 to 2 persons for most ADLs. Resident #75 required oxygen therapy. Record review of Resident #75's undated care plan revealed he had oxygen therapy for sleep apnea and respiratory failure. Record review of Resident #75's Order Summary Report dated 8/30/23 revealed an order to change respiratory tubing, mask, bottled water, clean filter every seven days on Friday night shift. There was an order for oxygen at 2-5 LPM by NC. Record review of Resident #75's NAR dated 8/01/23-8/31/23 revealed the change respiratory tubing, mask, bottled water, clean filter every seven days on Friday night shift was documented completed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 41 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 8/18/23 and 8/25/23. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 8/28/23 at 9:50 AM, Resident #75 was sitting up in bed with his oxygen on. The oxygen concentrator slatted vent on the back of the concentrator was covered in gray fuzz and dust-like particles. Surveyor unable to locate the oxygen concentrator filter. Resident #75 said he wore his oxygen all the time and the facility changed his oxygen tubing weekly. Resident #75 said he did not know when or if the facility cleaned the oxygen concentrator or filter. Residents Affected - Some During an observation on 8/29/23 at 9:28 AM revealed Resident #75's oxygen concentrator continued to have gray fuzz and dust-like particles in the slatted vent on the back of the concentrator. During an interview on 8/29/23 at 6:45 PM, LVN J said he had worked at the facility since June 2023 on the night shift. LVN J said he worked on Hall 200 from room [ROOM NUMBER] through 216. LVN J said the nurses were responsible for changing the resident's oxygen tubing, water, and cleaning the oxygen filters weekly usually on Sunday nights. LVN J said changing the tubing, water, and cleaning the oxygen filter would be scheduled on the NAR and the nurse would document on the NAR when the tasks were completed. LVN J said if the oxygen filters were not cleaned or if the tubing was not changed, the resident could get a respiratory infection and it would increase the resident's risk for infections. LVN J said he worked every other weekend and did not work last Sunday night, but he did work the previous Sunday night. Surveyor showed LVN J a picture of Resident #73's oxygen filter and asked LVN J if the filter looked to have been cleaned recently, and LVN J said that is bad, real bad. He said the oxygen filter did not look like it had been cleaned. During an interview on 8/30/23 at 8:17 AM, LVN G said she had worked at the facility for eight years and usually worked day shift on Hall 200. LVN G said the night shift nurses were responsible for changing the oxygen tubing and cleaning the oxygen filters on Sundays. LVN G said she checks the resident's oxygen to ensure it was set properly and had water, but she did not really check to see if it was changed or cleaned. LVN G said a dirty filter could reduce the amount of oxygen going through the tube and dust could get in the resident's lungs. LVN G said if oxygen tubing was not changed, bacteria could grow in the tubing. During an interview on 8/30/23 at 8:36 AM, ADON H said she had worked at the facility for three years. ADON H said she was responsible for ensuring everything was going smoothly and everyone was doing what they were supposed to do. ADON H said the night nurses were responsible for changing oxygen tubing and cleaning the oxygen concentrator filters on Sunday nights. ADON H said the resident could possibility get an infection from some type of germs if the oxygen tubing was not changed, or the oxygen concentrator filters were not cleaned. ADON H said she was made aware of the dirty oxygen filters on the evening of 8/29/23 and she cleaned all the filters herself. ADON H said she took responsibility for it not being done because she should have been checking to ensure it was being done. ADON H said the staff said they did not know where the filters were, and she was putting an in-service together and going to do one on one trainings with the nurses to ensure it would not be a problem in the future. During an interview on 8/30/23 at 9:29 AM, ADON K said she had worked at the facility since November 2022. ADON K said the nurses were responsible for changing the oxygen tubing and cleaning the oxygen filters every Sunday on night shift. ADON K said the resident could get a respiratory infection with a dirty oxygen filter or old oxygen tubing from dust and pollution. During an interview on 8/30/23 at 4:37 PM, the DON said she had worked at the facility for three (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 42 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 - Minimal harm or potential for actual harm years. The DON said the night nurses were responsible for changing oxygen equipment and cleaning oxygen filters on the on Sunday nights. The DON said the oxygen tubing changes and the oxygen filter cleanings were scheduled on the NAR and the nurses would document on the NAR when it was completed. The DON said the resident was at an increased risk of infection due to bacteria buildup if the oxygen filter was dirty and/or oxygen tubing was not changed. Residents Affected - Some During an interview on 08/30/23 at 4:41 p.m., the ADON H said cleaning concentrator filters were part of residents who required oxygen weekly orders. She said she was not aware the night nurses were not thoroughly cleaning the concentrator filters. She said she showed the 2-night nurses (LVN J and LVN P) how to thoroughly clean the concentrators filters after dirty filters were identified by staff and surveyors. The ADON H said concentrator filters should be clean to minimize respiratory infections. During an interview on 08/30/23 at 4:57 p.m., the DON said concentrators filters should have been cleaned or changed on Sunday nights. She said residents who required oxygen had an order written on the MAR. She said the unit managers should be following up to ensure filters were cleaned. The DON said concentrator filters should be kept clean to prevent bacteria from building up which could cause respiratory issues. During an interview on 08/30/23 at 5:24 PM, the administrator said he was not sure how often concentrator filters needed to be cleaned. He said if dust were on the filters, then they should have been cleaned. The administrator said the nursing managers and DON should be following up to ensure concentrator filters were clean. The administrator said concentrator filters should be clean to work properly and to help residents who require oxygen to receive clean air. During an interview on 8/30/23 at 5:34 PM, the Administrator said he would expect the residents' oxygen filters should be cleaned and the oxygen tubing should be changed per the physician's orders and the facility's policy. The Administrator said the resident could have respiratory issues if the oxygen filter was not cleaned or the oxygen tubing not changed. Requested a policy related to cleaning the oxygen concentrator filters on 8/30/23 at 1:55 PM, the DON said the facility did not have a policy related to cleaning the oxygen concentrator filters. Review of the facility's policy titled Oxygen Administration with a revised date of June 2020, indicated . all oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen . will be changed weekly and when visibly soiled, or as indicated by state regulation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 43 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of a face sheet dated 08/30/23 indicated Resident #23 was [AGE] year-old female and admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), hypertension (high blood pressure), atherosclerotic heart disease (is caused by plaque buildup in the wall of the arteries that supply blood to the heart), nonrheumatic mitral valve stenosis (is the heart valve that controls the flow of blood from the heart's left atrium to the left ventricle), congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should), and aortocoronary bypass graft (also called heart bypass surgery, is a medical procedure to improve blood flow to the heart). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated Resident #23 had adequate hearing, clear speech, and impaired vision. The MDS indicated Resident #23 had a BIMS score of 15 which indicated intact cognition and only required supervision for dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #23 was always continent for urinary and bowel. The MDS indicated Resident #23 received a diuretic during the last days of the assessment period. Record review of a care plan dated 06/29/21 indicated Resident #23 had hypertension. Intervention included give anti-hypertensive medications as ordered. Record review of a care plan dated 06/29/21 indicated Resident #23 had diabetes mellitus. Intervention included diabetes medication as ordered by doctor. Record review of a care plan dated 06/29/21 indicated Resident #23 had altered cardiovascular (relating to the heart and blood vessels) status as evidence by recent coronary artery bypass graft x2 (heart bypass surgery) due to myocardial infarction (heart attack). Record review of Resident #23's consolidated physician order dated 06/24/21 indicated Clopidogrel Bisulfate (is an antiplatelet medicine. This means it reduces the risk of blood clots forming) 75mg, give 1 tablet by mouth in the morning for cardiovascular disease. Record review of Resident #23's consolidated physician order dated 08/02/21 indicated Metformin tablet (is used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes) 500mg, give 1 tablet by mouth one time a day related to type 2 diabetes. Record review of Resident #23's consolidated physician order dated 09/08/21 indicated Entresto (is a brand-name oral tablet prescribed to treat certain types of heart failure) tablet 24-26 MG, give 1 tablet by mouth by mouth two times a day related to congestive heart failure. Record review of Resident #23's consolidated physician order dated 10/10/22 indicated Furosemide (Lasix; is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease) 20mg, give 1 tablet by mouth one time a day for edema. Record review of Resident #23's consolidated physician order dated 03/24/23 indicated Metoprolol Succinate Extended Release (is a beta-blocker used to treat chest pain (angina), heart failure, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 44 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 high blood pressure) 24-hour 25mg, give 0.5 tablet by mouth in the morning for hypertension. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #23's Electronic MAR indicated Clopidogrel Bisulfate 75MG scheduled for 8:00 a.m. indicated the following late administrations: Residents Affected - Some *08/19/23 at 3:41 p.m. by LVN D *08/21/23 at 9:37 a.m. by LVN D *08/22/23 at 11:29 a.m. by LVN C *08/23/23 at 10:33 a.m. by LVN C *08/24/23 at 9:19 a.m. by LVN D *08/25/23 at 9:13 a.m. by LVN D *08/27/23 at 10:46 a.m. by LVN C *08/28/23 at 9:30 a.m. by LVN C Record review of Resident #23's Electronic MAR indicated Metformin tablet 500mg scheduled for 8:00 a.m. indicated the following late administrations: *08/19/23 at 3:41 p.m. by LVN D *08/21/23 at 9:37 a.m. by LVN D *08/22/23 at 11:29 a.m. by LVN C *08/23/23 at 10:33 a.m. by LVN C *08/24/23 at 9:19 a.m. by LVN D *08/25/23 at 9:13 a.m. by LVN D *08/27/23 at 10:46 a.m. by LVN C *08/28/23 at 9:30 a.m. by LVN C Record review of Resident #23's Electronic MAR indicated Entresto 24-26mg scheduled for 8:00 a.m. and 7:00 p.m. indicated the following late administrations: *08/19/23 at 3:41 p.m. by LVN D *08/21/23 at 9:37 a.m. by LVN D *08/22/23 at 11:29 a.m. by LVN C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 45 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 *08/23/23 at 10:33 a.m. by LVN C Level of Harm - Minimal harm or potential for actual harm *08/24/23 at 9:19 a.m. by LVN D *08/25/23 at 9:13 a.m. by LVN D Residents Affected - Some *08/27/23 at 10:46 a.m. by LVN C *08/28/23 at 9:30 a.m. by LVN C Record review of Resident #23's Electronic MAR indicated Furosemide 20mg scheduled for 9:00 a.m. indicated the following late administrations: *08/19/23 at 3:41 p.m. by LVN D *08/22/23 at 11:30 a.m. by LVN C *08/23/23 at 10:34 a.m. by LVN C *08/27/23 at 10:47 a.m. by LVN C Record review of Resident #23's Electronic MAR indicated Metoprolol Succinate Extended Release 24-hour 25mg scheduled for 8:00 a.m. indicated the following late administrations: *08/17/23 at 10:20 a.m. by LVN C *08/18/23 at 11:31 a.m. by LVN C *08/21/23 at 9:37 a.m. by LVN D *08/22/23 at 11:29 a.m. by LVN C *08/23/23 at 10:33 a.m. by LVN C *08/24/23 at 9:19 a.m. by LVN D *08/25/23 at 9:13 a.m. by LVN D *08/27/23 at 10:46 a.m. by LVN C *08/28/23 at 9:30 a.m. by LVN C During an interview on 08/29/23 at 8:41 a.m., Resident #23 said her medication were given late sometimes. 4. Record review of a face sheet dated 08/30/23 indicated Resident #79 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves.), contracture (reduce joint mobility and restrict activities of daily living) left and right ankle, chronic pain syndrome (is a common problem that presents a major (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 46 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some challenge to health-care providers because of its complex natural history, unclear etiology, and poor response to therapy), and mood affective disorder (is a mental health condition that primarily affects your emotional state). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. The MDS indicated Resident #79 had minimal difficulty hearing, clear speech, and adequate vision. The MDS indicated Resident #79 had a BIMS score of 11 which indicated moderate cognitive impairment and did not reject care. The MDS indicated Resident #79 required extensive assistance for bed mobility and personal hygiene, and total dependence for dressing, toilet use and bathing. The MDS indicated Resident #79 was always incontinent of urinary and bowel. The MDS indicated Resident #79 received scheduled pain medication regimen. The MDS indicated Resident #79 received 7 days of an anticoagulant, antidepressant, and opioid during the assessment period. Record review of a care plan dated 04/06/23 indicated Resident #79 had GERD (Gastroesophageal reflux disease; is a common condition in which the stomach contents move up into the esophagus). Intervention included give medications as ordered. Record review of a care plan dated 04/06/23 indicated Resident #79 was on anticoagulant (are medicines that help prevent blood clots) therapy related to atrial fibrillation (is an irregular and often very rapid heart rhythm). Intervention included monitor/document/report to MD as needed signs and symptoms of complications. Record review of a care plan dated 04/06/23 indicated Resident #79 required pain management related to neuropathy (refers to any condition that affects the nerves outside your brain or spinal cord) and chronic pain syndrome. Intervention included anticipate resident's need for pain relief and respond immediately to any complaint of pain. Record review of a care plan dated 04/06/23 indicated Resident #79 required antidepressant medication for diagnosis of depression. Intervention included give antidepressant medications ordered by physician. Record review of Resident #79's consolidated physician order dated 03/21/23 indicated Eliquis (is used to lower the risk of stroke or a blood clot in people with a heart rhythm disorder called atrial fibrillation) Oral Tablet 5mg (Apixaban), give 1 tablet by mouth two times a day for AFIB. Record review of Resident #79's consolidated physician order dated 04/04/23 indicated Hydrocodone-Acetaminophen (combine to treat moderate pain) Oral Tablet 10-325mg, give 1 tablet by mouth three times a day for chronic pain. Record review of Resident #79's consolidated physician order dated 06/12/23 indicated Metoclopramide (is a medication that treats the symptoms of gastroesophageal reflux disease (GERD)) HCL Oral Tablet 5mg, give 5mg by mouth four times a day for GERD. Record review of Resident #79's consolidated physician order dated 06/12/23 indicated Venlafaxine (is used to treat depression) HCL Oral Tablet 75mg, give 75mg by mouth two times a day for depression. Record review of Resident #79's consolidated physician order dated 08/15/23 indicated Lasix (is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 47 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 Level of Harm - Minimal harm or potential for actual harm disease, and kidney disease) Oral tablet 20mg (Furosemide), give 1 tablet by mouth one time a day for edema. Record review of Resident #79's Electronic MAR indicated Eliquis Oral Tablet 5mg scheduled for 8:00 a.m. and 7:00 p.m. indicated the following late administrations: Residents Affected - Some *08/15/23 at 9:43 a.m. by LVN D *08/16/23 at 9:23 a.m. by LVN D *08/17/23 at 10:33 a.m. by LVN C *08/18/23 at 11:26 a.m. by LVN C *08/19/23 at 3:45 p.m. by LVN D *08/20/23 at 10:07 a.m. by LVN D *08/21/23 at 10:13 a.m. by LVN D *08/21/23 at 8:45 p.m. by LVN BB *08/22/23 at 11:33 a.m. by LVN C *08/23/23 at 12:25 p.m. by LVN C *08/24/23 at 10:20 a.m. by LVN D *08/25/23 at 10:08 a.m. by LVN D *08/27/23 at 10:24 a.m. by LVN C *08/28/23 at 10:27 a.m. by LVN C *08/29/23 at 9:23 a.m. by LVN C Record review of Resident #79's Electronic MAR indicated Hydrocodone-Acetaminophen Oral Tablet 10-325mg scheduled for 9:00 a.m., 5:00 p.m. and 1:00 a.m. indicated the following late administrations: *08/16/23 at 3:51 a.m. by LVN BB *08/17/23 at 10:33 a.m. by LVN C *08/18/23 at 2:22 a.m. by ADON K *08/18/23 at 11:26 a.m. by LVN C *08/19/23 at 3:45 p.m. by LVN D (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 48 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 *08/20/23 at 6:38 p.m. by LVN D Level of Harm - Minimal harm or potential for actual harm *08/21/23 at 2:13 a.m. by LVN BB *08/21/23 at 7:30 p.m. by LVN D Residents Affected - Some *08/22/23 at 3:33 a.m. by LVN BB *08/22/23 at 11:34 a.m. by LVN C *08/23/23 at 12:25 p.m. by LVN C *08/24/23 at 10:21 a.m. by LVN D *08/25/23 at 3:15 a.m. by LVN BB *08/25/23 at 7:20 p.m. by LVN BB *08/ 27/23 at 10:25 a.m. by LVN C *08/28/23 at 10:27 a.m. by LVN C *08/29/23 at 4:38 a.m. by ADON K Record review of Resident #79's Electronic MAR indicated Lasix Oral tablet 20mg scheduled for 9:00 a.m. indicated the following late administrations: *08/17/23 at 10:33 a.m. by LVN C *08/18/23 at 11:26 a.m. by LVN C *08/19/23 at 3:45 p.m. by LVN D *08/21/23 at 10:13 a.m. by LVN D *08/22/23 at 11:34 a.m. by LVN C *08/23/23 at 12:25 p.m. by LVN C *08/24/23 at 10:21 a.m. by LVN D *08/27/23 at 10:25 a.m. by LVN C *08/28/23 at 10:27 a.m. by LVN C Record review of Resident #79's Electronic MAR indicated Metoclopramide HCL Oral Tablet 5mg scheduled for 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. indicated the following late administrations: *08/15/23 at 9:43 a.m. by LVN D (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 49 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 *08/15/23 at 1:22 p.m. by LVN D Level of Harm - Minimal harm or potential for actual harm *08/16/23 at 9:23 a.m. by LVN D *08/17/23 at 12:42 a.m. by LVN BB Residents Affected - Some *08/17/23 at 10:33 a.m. by LVN C *08/18/23 at 11:26 a.m. by LVN C *08/19/23 at 3:45 p.m. by LVN D (due at 8:00 a.m.) *08/19/23 at 3;45 p.m. by LVN D (due at 12:00 p.m.) *08/20/23 at 10:07 a.m. by LVN D *08/20/23 at 3:24 p.m. by LVN D (due at 12:00 p.m.) *08/21/23 at 10:13 a.m. by LVN D *08/21/23 at 7:30 p.m. by LVN D (due at 12:00 p.m.) *08/22/23 at 11:33 a.m. by LVN C (due at 8:00 a.m.) *08/23/23 at 12:25 p.m. by LVN C (due at 8:00 a.m.) *08/24/23 at 10:20 a.m. by LVN D (due at 8:00 a.m.) *08/24/23 at 2:13 p.m. by LVN D *08/25/23 at 10:08 a.m. by LVN D *08/25/23 at 2:39 p.m. by LVN D *08/25/23 at 7:20 p.m. by LVN BB (due at 4:00 p.m.) Record review of Resident #79's Electronic MAR indicated Venlafaxine HCL Oral tablet 75mg scheduled for 8:00 a.m. and 5:00 p.m. indicated the following late administrations: *08/15/23 at 9:43 a.m. by LVN D *08/16/23 at 9:23 a.m. by LVN D *08/17/23 at 10:33 a.m. by LVN C *08/18/23 at 11:26 a.m. by LVN C *08/19/23 at 3:45 p.m. by LVN D (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 50 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 *08/20/23 at 10:07 a.m. by LVN D Level of Harm - Minimal harm or potential for actual harm *08/20/23 at 6:38 p.m. by LVN D *08/21/23 at 10:13 a.m. by LVN D Residents Affected - Some *08/21/23 at 7:30 p.m. by LVN D *08/22/23 at 11:33 a.m. by LVN C *08/23/23 at 12:25 p.m. by LVN C *08/24/23 at 10:21 a.m. by LVN D *08/24/23 at 6:54 p.m. by LVN D *08/25/23 at 10:08 a.m. by LVN D *08/25/23 at 7:20 p.m. by LVN BB *08/27/23 at 10:24 a.m. by LVN C *08/28/23 at 10:27 a.m. by LVN C *08/29/23 at 9:23 a.m. by LVN C During an interview on 08/28/23 at 12:27 p.m., Resident #79 said her medication were not given on time. She said she did not get her morning medication until around 9:30 a.m. or 10:00 a.m. and her evening medications were late also. During an interview on 08/30/23 at 2:07 p.m., LVN D said she documented her medication administration as she was passing medications or in real time. She said timed medications were allowed to be given 1 hour before or 1 hour after scheduled time. LVN D said if a medication said daily or in the AM/PM then it could be given between 7am-10am or 7pm-10pm. LVN D said residents did complain about their medication being given late. She said medication should be given at the ordered time to follow the facility's policy and to ensure the next dosage could be given at the right time. LVN D said the managers and DON should oversee LVNs to ensure medications were given on schedule. During an interview on 08/31/23 at 8:20 a.m., LVN C said she pulled her medications, compared label with order, verified correct resident then administrated and documented on the electronic MAR. She said scheduled medication should be given 1 hour before or 1 hour after to be considered on time. LVN C said she had given late medications because sometimes crisis happened. She said it depended on the medication if it was an issue given multiple doses to close together. LVN C said sometime medication had to be given early or late to get the medication back on schedule. She said it was important to give scheduled medication on time because the body was used to get it at a certain time, and it could be a specific reason why it was ordered at that time. She said the managers and DON should oversee LVNs to ensure medications were given on schedule. During an interview on 08/31/23 at 9:45 a.m., the DON said nurses should document medication given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 51 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 Level of Harm - Minimal harm or potential for actual harm immediately after administration. She said scheduled medication should be given 1 hour before or 1 hour after to be considered on time. The DON said LVNs were responsible for timely medication administration. She said managers should review records randomly and weekly to ensure LVNs were administrating medication on time. The DON said it was important to administrate medication timely to provide better care to the residents. Residents Affected - Some During an interview on 08/31/23 at 10:41 a.m., the Administrator said medications should be passed as indicated. He said LVNs were responsible for timely medication administration. The Administrator said late medication could result in adverse reaction and cause change in a resident condition. Record review of a facility General Guidelines for Medication Administration revised date 08/20 indicated .a schedule of routine dose administration times is established by the facility and utilized on the administration record .medications are administered within 60 minutes of the scheduled administration time . Record review of facility's policy Controlled Substances revised on 08/2020, indicated .Medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with state and federal laws and regulations . 5. Accurate inventory of all controlled medications is maintained at all times. When a controlled substance is administered, the licensed nursing personnel administering the medication immediately enters the following information on the accountability record and the Medication Administration Record (MAR): a. Date and time of administration (MAR and Accountability Record) b. Amount administered (Accountability Record) c. Remaining quantity (Accountability Record) d. Signature of the nursing personnel administering the dose (Accountability Record) e. Initials of the nurse administering the dose, completed after the medication has been administered (MAR). 6. When a dose of a controlled medication is removed from the container of administration but is refused by the resident or not given for any reason, the dose is not placed back in inventory. The dose must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose . Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 4 of 6 residents (Resident #s 9, 68, 23, 79) reviewed for pharmacy services. ADON K failed to ensure she had a witness when wasting Resident #9's acetaminophen-codeine 300-60mg tablet (controlled medication used for pain). The facility failed to ensure Resident #68's Lorazepam (controlled antianxiety medication) was accurately reconciled. The facility failed to administer Resident #23 and Resident #79's scheduled medication per the facility's policy timeframe. These failures could place the residents at risk of not having medications available for use, not receiving medications, and drug diversion. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 52 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. Record review of Resident #9's face sheet dated 08/30/23, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of encephalopathy (brain disease that alters brain function or structure), dementia (memory loss), pain, and anxiety. Record review of Resident #9's quarterly MDS assessment dated [DATE], indicated she rarely/never understood or understood others. The MDS indicated Resident #9's staff assessment for mental status indicated Resident #9 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #9 was totally dependent on staff for bed mobility, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #9 did not receive any opioid medications within the last 7 days of the look back period. Record review of Resident #9's order summary report dated 08/30/23, indicated the following orders: *Acetaminophen-codeine 300-60mg: give 1 tablet via gastrostomy tube (tube inserted through the belly) four times a day for chronic pain with a start date of 12/23/21. *Acetaminophen-codeine 300-60mg: give 1 tablet via gastrostomy tube every 4 hours as needed for pain with a start date of 12/23/21. Record review of Resident #9's undated comprehensive care plan indicated she had a potential for pain related to diagnoses of diabetes (group of diseases that result in too much sugar in the blood), osteoporosis (condition in which bones become weak and brittle), and chest pain. The care plan also indicated Resident #9 received pain medications as needed. The care plan interventions indicated to administer analgesia (pain reliever) as per orders and to monitor/document for side effects of pain medications. During an observation and interview at 08:59 AM, ADON K and LVN V were counting the narcotic medications for the medication cart for hall 300 rooms 316-331 as ADON K was ending her shift. During the count, Resident #9's controlled administration record for acetaminophen-codeine tablet indicated Resident #9 had 31 tablets left. The medication card for acetaminophen-codeine tablet indicated she had 30 tablets left. This indicated 1 tablet of acetaminophen-codeine was missing. ADON K said she told LVN AA she had dropped Resident #9's acetaminophen-codeine tablet last night and needed her to come and sign as a witness. ADON K said Resident #9's medication was given crushed, so she had to obtain another tablet because it had spilled on the floor. ADON K said she did not get LVN AA to sign the controlled medication records, as she had been busy all night and forgot when LVN AA arrived at the floor. Record review of Resident #9's controlled administration record for acetaminophen-codeine 300-60mg tablet dated 08/15/23-08/29/23, indicated ADON K signed out one tablet at 0200 (2 AM) on 08/29/23 with 31 tablets remaining. The controlled administration record did not indicate any medication was wasted or witnessed. During an interview on 08/29/23 at 11:03 AM, the DON said she would expect the nurses to notify her of any narcotic medication discrepancies immediately. The DON said ADON K was coming to talk to her about what had happened. The DON said ADON K should have had another nurse sign as a witness that the medication had been wasted at the time the incident occurred. The DON said ADON K was responsible for notifying her of the wasted medication. During an interview on 08/29/23 at 6:10 PM, LVN AA said she was not called by ADON K last night to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 53 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sign as a witness for a medication that had been wasted and did not witness a medication being wasted by ADON K. During an interview on 08/29/23 at 6:21 PM, the DON said she was aware of LVN AA not witnessing ADON K wasting Resident # 9's acetaminophen-codeine tablet. The DON said she had started her investigation as per the facility's policy. 2. Record review of Resident #68's face sheet dated 08/30/23, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included seizures, anxiety, gastro-esophageal reflux disorder (digestive disease in which stomach acid or bile irritates the food pipe lining), and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of Resident #68's comprehensive care plan revised on 01/09/23, indicated she required psychotropic medications for diagnoses of affective mood disorder, anxiety, and depression. The care plan interventions indicated to administer medications as ordered and to monitor side effects and effectiveness. Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated she usually made herself understood and understood others. The MDS indicated Resident #68 had a BIMS score of 13, indicating her cognition was intact. The MDS indicated #68 required supervision with all ADLs. The MDS indicated Resident #68 had received antianxiety medications 6 days of the 7 day look back period. Record review of Resident #68's order summary report dated 08/30/23, indicated she had an order for lorazepam 1 mg give one tablet by mouth in the evening for anxiety disorder with a start date of 04/20/23. During an observation and interview on 08/29/23 at 10:24AM, the middle hall short cart was reviewed for accuracy for reconciliation of narcotic medications and was noted Resident #68's Lorazepam 1mg medication card indicated she had 14 tablets left. The controlled drug administration record for Lorazepam 1mg indicated she had 13 tablets remaining. LVN R and LVN G corrected the count by making a line through the administration dated for 08/28/23 at 8:00 PM making the count correct. LVN R said it appeared Resident #68 did not receive her Lorazepam on 08/28/23 at 8:00 PM as Resident #68 had an extra tablet. LVN R said she counted the cart with the LVN U that morning and she did not know how that was missed. Record review of Resident #68's controlled drug administration record for lorazepam 1 mg tablet dated 08/12/23-08/28/23, indicated LVN U signed out she administered one tablet on 08/28/23 at 8:00 PM with 13 tablets remaining. Record review of Resident #68's MAR for August 2023, indicated Lorazepam 1mg was administered at 8:00 PM on 08/28/23 by LVN U. During an interview on 08/29/23 at 11:03 AM, the DON said if there was an extra tablet in the packet then it was considered as the medication was not given. During an interview on 08/30/23 at 1:40 PM, LVN U said she remembered popping the blister pack and said she must have popped the wrong hole. LVN U said she thought she had given Resident #68 her Lorazepam 1mg tablet. LVN U said since there was an extra tablet in the medication card she probably did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 54 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not administer the Lorazepam to Resident #68 as she was the only one that gave her the Lorazepam. LVN U said was unsure who she counted the medication cart with, but remembers the count being correct when she left. During an interview on 08/30/23 at 04:19 PM, ADON O said she expected the DON, medical director, and family to be notified as soon as a medication discrepancy was identified. ADON O said there should be a witness when a nurse wastes a narcotic medication. ADON O said she expected the nurse to find a witness as there was never just one nurse in the building. ADON O said the nurse was responsible for counting the narcotic medications prior to obtaining responsibility of that cart and ensuring the count was correct. During an interview on 08/30/23 at 4:50 PM, the Administrator said with a narcotic medication discrepancy he expected the DON to be notified. The Administrator said he expected the nurse to have a witness when wasting a narcotic medication. The Administrator said failure to do so would cause the employee to be suspended pending investigation, notifying HHSC, notifying the medical director, and calling the local authorities. The Administrator said the charge nurse was responsible for counting the medication cart before and at end of shift with the oncoming nurse or the nurse that was leaving. The Administrator said if the narcotic count indicated there was an extra tablet, then the medication was considered as not administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 55 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 medication carts and 3 of 27 residents reviewed in sample (Resident #319, Resident #13 and Resident #81 ). The facility failed to have Resident #319's Arthritis hot pain cream stored and locked in an area not accessible to other staff, residents, or visitors. The facility failed to ensure Resident #13 did not have prescribed and OTC medications at bedside. ADON K failed to ensure the medication cart for hall 300 rooms 316-331 was locked when it was left unattended while giving Resident #81's medication. ADON K and LVN V failed to ensure the medication cart for hall 300 rooms 316-331 was locked when it was left unattended. These failures could place residents at risk of injury. Findings included: 1.Record review of Resident #319's face sheet dated 08/30/23 indicated she was a [AGE] year-old female that admitted to the facility on [DATE] with the diagnoses of diabetes, kidney disease, and chronic pain. Record review of Resident #319's MDS assessment dated [DATE] indicated she had a BIMS score of 11 which means she had moderately impaired cognition. The MDS also indicated she required extensive assistance of 2 staff for bed mobility and extensive assistance of 1 staff for transfers, bathing, toileting, and dressing, and supervision for eating. Record review of Resident #319's order summary report dated 08/30/23 indicated she did not have an order for arthritis hot pain cream. During an observation and interview on 08/29/23 at 08:53 AM Resident #319 had a container of arthritis hot pain cream on dresser beside her bed. Resident said she used the cream on her hands and her knees when she needs to, and it really helped her. She said her family member brought it for her a couple days ago, but 08/29/23 was her first day to try it. During an observation on 08/30/23 at 08:35 AM Resident #319 was sitting in her room in her wheelchair. The container of arthritis hot pain cream continues to lay on her dresser. She said she needed to use it because she had been having some issues with her knees and back, but her nurse had just given her medications to help. During an observation and interview on 08/30/23 at 04:40 PM LVN N said no residents were allowed to have medications kept in their rooms. LVN N went to Resident #319's room and removed the arthritis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 56 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0761 Level of Harm - Minimal harm or potential for actual harm hot pain cream and said she was going to contact the physician and obtain an order for the cream for the staffed nurses to give to Resident #319 as needed. LVN N said that she did not see the cream on Resident #319's dresser, but all staff were responsible for ensuring medications were not in resident's rooms. She said medications left in resident's rooms placed a risk for wandering residents to get the medication and overdose or possibly use in their eyes. Residents Affected - Few During an interview on 08/30/23 at 04:51 PM the ADON said medications were not supposed to be at any resident's bedside. She said nurses, as well as any staff who went into Resident #319's room was responsible for ensuring no medications were in the room. The ADON said with medications being left in Resident #319's room, it placed a risk for the medications to be used in the wrong way, overdosing, and allowing other residents to pick the medicine up and use. During an interview on 08/30/23 at 05:09 PM the DON said no residents were to have medications at bedside. She said she expected residents and families to give any medications they get outside of the facility to the staffed nurse to handle properly. The DON said all staff were responsible for ensuring there are no medications in resident rooms and should have been more observant. The DON said with medications being left at Resident #319's bedside it placed a risk for anyone picking the medication up and ingesting, using the medication in an unproper way, or could have had an allergy to the medication. During an interview on 08/31/23 at 09:49 AM the Administrator said all medications should be stored in nurse carts or medication room with lock and key. He said all staff are responsible for ensuring residents do not have medications at the bedside. The Administrator said having medications in resident rooms placed a risk for not having physician orders and not safely administering medications to residents. 2.Record review of Resident #13's face sheet dated 08/30/23, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dysphagia (difficulty swallowing), anxiety and depression (disorder characterized by persistently depressed mood or loss of interest in activities). Record review of Resident #13's order summary report dated 08/30/23, indicated the following orders: *Aspirin 81mg give one tablet by mouth one time a day for supplement with a start date of 01/03/21. *B complex vitamin give one tablet by mouth one time a day for supplement with a start date of 01/03/21. *Calcium 500+D3 tablet give one tablet by mouth one time a day for supplement with a start date of 09/17/20. *Centrum Adults tablet give one tablet by mouth one time a day for supplement with a start date of 09/17/20. *Coenzyme Q10 (acts as an antioxidant, which protects cells from damage and plays an important part in your metabolism) give one capsule by mouth in the morning for hyperlipidemia with a start date of 09/17/20. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 57 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0761 Level of Harm - Minimal harm or potential for actual harm *Coreg 25 mg give one tablet by mouth in the morning for essential hypertension (high blood pressure) with a start date of 08/25/22. *Digoxin 125 mcg give one tablet by mouth one time day for atrial fibrillation (irregular heartbeat) with a start date of 04/12/23. Residents Affected - Few *Diltiazem 120 mg give one capsule by mouth in the morning for atrial fibrillation with a start date of 09/16/20. *Furosemide 20 mg give three tablets by mouth in the morning for fluid retention with a start date of 09/17/20. *Glimepiride 1 mg give one tablet by mouth one time a day for diabetes with a start date of 09/17/20 *Magnesium 400 mg give one tablet by mouth two times a day for supplement with a start date of 07/17/23. *Oxybutynin 10 mg give one tablet by mouth one time a day for overactive bladder with a start date of 12/11/20. *Pepcid 20 mg give one tablet by mouth two times a day for supplement with a start date of 01/03/21. *Potassium 20 MEQ give one tablet by mouth one time a day for supplement with a start date of 12/10/20. *Prilosec 20 mg give one tablet by mouth two times a day for GERD (digestive disease in which stomach acid or bile irritates the food pipe lining) with a start date of 12/14/20. *Tramadol 50 mg give two tablets by mouth three times a day for chronic pain with a start date of 07/16/22. *Venlafaxine 75 mg give one tablet by mouth two times a day for depression with a start date of 01/20/23. *Vitamin C 1000 mg give one tablet by mouth two times a day for supplement with a start date of 01/03/21. *Vitamin D3 125 mcg give two capsules by mouth one time a day for supplement with a start ate of 01/03/21. *Zinc 50 mg give 2 tablets by mouth one time a day for supplement with a start date of 01/03/21. Record review of Resident #13's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS indicated Resident #13 had a BIMS score of 15, which indicated her cognition was intact. The MDS indicated Resident #13 required supervision with bed mobility, transfer, walking, locomotion, dressing, eating, toileting, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 58 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0761 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #13's undated comprehensive care plan indicated she had diagnoses of overactive bladder, stroke, diabetes, hyperlipidemia, hypertension, fluid retention, anxiety, renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease), depression and was at risk for pain. The care plan interventions indicated to administer medications as ordered. Residents Affected - Few During an observation and interview on 08/28/23 at 10:03 AM, Resident #13 was sitting up in her wheelchair in her room. A bottle of lubricating eye drops was on her bed. Resident #13 said she had the eye drops due to her dry eyes. Resident #13 also had a bottle of cranberry 500 mg tablets in a white basket that was on top of the seat of the recliner. Inside the white basket were also 2 medicine cups with pills. Resident #13 said the pills were her pills of the day that LVN CC had left for her to take as she knows she will take them. Resident #13 said the nurse comes back and checks to see if I took them. During an observation and interview on 08/28/23 at 10:12 AM, LVN CC entered Resident #13's room and obtained the bottle of cranberry tablets, the lubricating eye drops and the 2 medicine cups with pills. LVN CC said she had given Resident #13 her medications to take that morning, turned her back, and then administered Resident #13's roommate her medications. LVN CC said she figured Resident #13 had taken the medications. LVN CC said the pills in the medication cups were Resident #13's morning medications. One medicine cup had 12 unidentified pills and the other had 6 unidentified pills which were left from her morning medications. LVN CC said Resident #13 liked her prescription medications in one cup and her OTC medications in another cup. LVN CC said the risk of Resident #13 having medications at bedside was someone could go in and take them or Resident #13 could take them whenever she wanted. LVN CC said she was responsible for ensuring Resident #13 took her medications. LVN CC said she was unaware Resident #13 had a bottle of cranberry tablets or the lubricating eye drops. LVN CC said the family tends to bring OTC medications and place them wherever they want. LVN CC said the risks of having OTC medications at bedside was someone could come in and take them. LVN CC said she was responsible for ensuring the residents did not have OTC medications at bedside. LVN CC said if medications were kept at beside there should be a physician's order indicating this and a self-administration assessment completed. LVN CC said she had not completed a self-administration assessment on Resident #13. During an interview on 08/30/23 at 4:19 PM, ADON O said she expected the nurse to ensure medications were taken unless the resident had an order for self-administration. ADON O said by not ensuring medications were taken could cause a resident to miss a dose, resident could forget to take them, or other residents could take them. ADON O said the nurse who was administering the medications was responsible for ensuring medications were taken and not left at bedside. ADON O said OTC medications were not to be at bedside unless the resident had an order and an assessment that they could have at bedside. ADON O said by not knowing if a resident had OTC medications at bedside could cause medication to interfere with medications they were currently taking. ADON O said everyone was responsible for ensuring OTC medications were not at bedside. During an interview on 08/30/23 at 4:50 PM, the Administrator said he expected the nurse to ensure medications were taken by the resident. The Administrator said OTC medications should be kept under lock and key to ensure proper administration. The Administrator said residents could have medications at bedside if they had a physician's order for self-administration. The Administrator said by having medications at bedside, anyone could go in the room and ingest them. During an interview on 08/30/23 at 5:22 PM, the DON said she expected medications not to be left at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 59 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bedside and expected the nurse to ensure the resident took them as it was their responsibility. The DON said she expected the family and resident to notify them if they bring or order OTC medications to the facility. The DON said having medications at bedside could cause an adverse event. 3. Record review of Resident #81's face sheet dated 08/30/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis that affects all four limbs, plus torso), diabetes mellitus (a group of diseases that result in too much sugar in the blood), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety. Record review of Resident #81's order summary report dated 08/30/23, indicated he had the following orders: *insulin glargine (long-acting type of insulin that works slowly) 100unit/ml inject 15 units subcutaneously (under the skin) in the morning for diabetes with a start date of 03/06/23. *Novolog flex pen (fast-acting insulin) 100unit/ml inject per sliding scale subcutaneously before meals and at bedtime for diabetes with a start date of 02/24/23. Record review of Resident #81's comprehensive care plan revised on 04/03/23, indicated he had a diagnoses of diabetes mellitus with interventions to administer diabetic medications as ordered. Record review of Resident #81's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #81 had a BIMS score of 15, indicating his cognition was intact. The MDS indicated he was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated he received insulin injections 7 out of the 7 days of the look back period. During an observation on 08/29/23 at 08:30 AM, ADON K entered Resident #81's room to obtain a blood sugar check. ADON K left the medication cart unlocked. A staff member came and stood next to the medication cart waiting on ADON K. Multiple staff members were observed passing down the hallway. During an interview on 08/29/23 at 08:59 AM, ADON K said it was the nurse's responsibility to keep the cart locked when not present. ADON K said someone could have opened the cart and obtained medications. 4. During an observation and interview on 08/29/23 at 09:17 AM, the 316-331 medication cart was parked outside room [ROOM NUMBER], a supply room. The medication cart was noted to be unlocked. There was not a staff member present. LVN V came out of the supply room, and said she was the one responsible for leaving the cart unlocked. LVN V said she went to the supply room to obtain a syringe. LVN V said she was responsible for ensuring the medication cart was kept locked when left unattended. LVN V said by not locking the medication cart, someone could take the medications. During an interview on 08/30/23 at 4:19 PM, ADON O said the medication carts should be kept locked when unattended for safety. ADON O said the nurse was responsible for ensuring the cart was kept locked. During an interview on 08/30/23 at 4:50 PM, the Administrator said he expected the medication carts to be always locked when left unattended. The Administrator said leaving the cart unlocked could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 60 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cause medications to be taken. The Administrator said the charge nurse was responsible for locking the cart. During an interview on 08/30/23 at 5:22 PM, the DON said the nurses were responsible for locking their medication carts. The DON said not locking the medication carts someone could get into the medications inside the cart. Record review of the facility's policy General Guidelines for Medication Administration revised on 08/2020, indicated .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer .15. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide . Record review of the facility's policy Storage of Medications revised on 08/2020 indicated . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .3. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 61 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 review the facility failed to ensure safe and sanitary storage of resident's food items for 2 of 3 residents reviewed for personal food safety. (Resident #16 and Resident #34) Residents Affected - Few The facility did not implement the personal food policy related to personal refrigerators for Resident's #16 and Resident #34. These failures could place the residents at risk for food borne illness. The findings included: 1. Record review of Resident #16's face sheet dated 8/30/23 indicated she was a 100year old female who admitted to the facility on [DATE] with the diagnoses of high blood pressure, breast cancer, heart failure, and need for assistance with personal care. Record review of Resident #16's MDS assessment dated [DATE] indicated that she had a BIMS score of 12 which meant she had moderately impaired cognition. The MDS also indicated that resident required extensive assistance of 2 staff for bed mobility, extensive assistance of 1 staff for transfers, toileting, dressing, and eating, and total assistance of 1 staff for bathing. During an observation on 8/28/23 at 10:07 AM, Resident #16's refrigerator was in her room with temperature check sheet located on the outside of the refrigerator dated July 2023 with no temperatures on the sheet. There was no thermometer located in the refrigerator. During an observation on 8/29/23 at 09:15 AM, Resident #16's refrigerator continued to have a July 2023 dated paper on the front of the refrigerator with no temperatures and no thermometer inside. During an observation on 8/30/23 at 08:42 AM, Resident #16's refrigerator had a new undated temperature sheet on the outside of the refrigerator that was blank. There was no thermometer found inside. During an observation on 8/30/23 at 04:36 PM, Resident #16's refrigerator had an undated sheet on the outside of the refrigerator with a date written in as 8/30/23 and a temperature of 40 degrees signed by Housekeeper L. During an interview on 8/30/23 at 04:34 PM, CNA M said the housekeeping department was responsible for checking resident refrigerators. She said she had not noticed them being checked but she knew a housekeeper checked Resident #16's refrigerator on 8/30/23. During an interview on 8/30/23 at 04:51 PM, ADON O said housekeeping was responsible for checking refrigerator temperatures daily. She said there should have been a thermometer in the refrigerator. ADON O said the failure could have caused Resident #16 to consume spoiled food. During an interview on 8/30/23 at 05:09 PM, the DON said the temperature checks on Resident #16's refrigerator was assigned to the housekeepers. She said they should be checked daily. The DON said with the refrigerators not being checked, it could cause bacteria growth if temperatures are not within range and if resident consumes items in their refrigerator there could be adverse effects. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 62 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/31/23 at 09:52 AM, the Administrator said he expected the resident refrigerators to be checked daily. He said the housekeepers and housekeeping supervisor were responsible for ensuring the refrigerator temperatures for all residents were completed daily. He said the risk for Resident #16 is that the refrigerator not cooling properly, and resident ingesting spoiled or expired food. 2. Record review of Resident #34's face sheet, dated 8/29/23, indicated Resident #34 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of heart failure, shortness of breath, high blood pressure, diabetes (high blood sugar), weakness, and abnormality of gait, and anxiety (nervousness). Record review of Resident #34's quarterly MDS assessment, dated 7/07/23, indicated Resident #34 had clear speech and was understood by staff. The MDS indicated Resident #34 was able to understand others. The MDS indicated Resident #34 had a BIMS of 12, which indicated moderate cognitive function impairment. During an observation and interview on 8/28/23 at 10:15 AM, Resident #34 had a temperature log on her personal refrigerator dated July at the top of log, but there were no temperatures recorded on the July temperature log and there was no log for August posted. Resident's refrigerator was packed full of food and unable to determine if there was a thermometer in it. Resident #34 said she did not know when the last time anyone had checked her refrigerator. During an observation and interview on 8/29/23 at 9:35 AM, Resident #34's personal refrigerator July temperature log was removed, and an August temperature log was posted on the front of the refrigerator. There were no temperatures documented 8/01/23-8/29/23. There was a thermometer in the refrigerator door and surveyor observed the temperature to be 49 degrees and there was significantly less food in the refrigerator than observed on 8/28/23. Resident #34 said the staff had come in that morning and cleaned the refrigerator out and placed a new temperature log for August on the refrigerator. During an interview on 8/30/23 at 8:36 AM, the ADON H said she had worked at the facility for three years and was responsible for ensuring everything was going smoothly on Hall 200 and ensuring everyone was doing what they were supposed to do. ADON H said the personal refrigerators should be checked by housekeeping when they cleaned the resident's room and document the temperature on the temperature log. ADON H said monitoring personal refrigerators was important to ensure food is stored at proper temperature to prevent food from spoiling and making residents sick. During an interview on 8/30/23 at 2:37 PM, the Housekeeping Supervisor said she had worked at the facility since December 2022 in housekeeping, but she had been the Housekeeping Supervisor for about a month. The Housekeeping Supervisor said all of housekeeping was responsible for the personal refrigerators. The Housekeeping Supervisor said housekeeping should be checking the refrigerators weekly, along with cleaning it, removing expired food out of it, checking the temperature, and documenting it on the temperature log on the front of the refrigerator. The Housekeeping Supervisor said she was responsible for ensuring the personal refrigerators were being monitored and temperature logs were being completed. The Housekeeping Supervisor said it was important to ensure refrigerated items were checked and temperature logs were completed appropriately to ensure refrigerators were functioning properly to keep food from spoiling and removing expired food, so residents do not get sick. The Housekeeping Supervisor said there had been a high turnover of housekeeping staff and she may not have checked behind the staff to ensure the personal refrigerators were being monitored and temperatures checked and logged for Resident #34. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 63 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0813 Level of Harm - Minimal harm or potential for actual harm During an interview on 8/30/23 at 4:37 PM, the DON said she had worked at the facility for three years. The DON said it was the responsibility of housekeeping for monitoring the personal refrigerators for expired foods, checking, and documenting the temperatures of the personal refrigerators. The DON said it was important to monitor the refrigerators for expired foods and check the temperature of the refrigerator to ensure it was functioning properly, so food did not spoil and grow bacteria that could make residents sick. Residents Affected - Few During an interview on 8/30/23 at 5:34 PM, the Administrator said he would expect the personal refrigerators to be checked weekly and temperatures checked and documented on the temperature log, to ensure the food was kept at an appropriate temperature to prevent food spoiling and potentially causing the resident to get sick, and ensure the refrigerator was functioning properly. Record review of the facility's policy, titled Refrigerator-Personal dated 5/2017, indicated . the resident's refrigerators would be checked weekly for cleanliness and remaining sanitary . Housekeeping Supervisor/designee would monitor resident's refrigerator weekly . clean and remove expired food as needed . keep thermometer in refrigerator and maintain at 41 degrees or below . log temperature weekly when checked . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 64 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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** 3. Record review of a face sheet dated 08/30/23 indicated Resident #32 was a [AGE] year-old male and admitted on [DATE] for diagnoses including chronic kidney disease (is a condition in which the kidneys are damaged and cannot filter blood as well as they should), flaccid hemiplegia (severe or complete loss of motor function on one side of the body) and need for assistance with personal care. Residents Affected - Some Record review of a quarterly MDS assessment dated [DATE] indicated Resident #32 was understood and understood others. The MDS indicated Resident #32 had a BIMS score of 14 which indicated intact cognition and required total dependence for ADLs except eating. The MDS indicated Resident #32 had upper and lower extremity limited range of motion to one side of the body. The MDS indicated Resident #32 was always incontinent of urine and bowel. Record review of a care plan revision dated of 02/27/19 indicated Resident #32 had an ADL self-care performance deficit related to weakness and deconditioning. Intervention included 1 staff extensive participation with toileting. During an observation on 08/29/23 at 10:24 a.m., CNA A provided Resident #32 incontinence care for urine. CNA A never changed her gloves after she started performing perineal care. CNA A cleaned Resident back to front instead of front to back. CNA A opened Resident #32's door handle and linen barrel with dirty gloves. CNA A removed dirty gloves put items away then used hand gel. 4. Record review of a face sheet dated 08/30/23 indicated Resident #23 was [AGE] year-old female and admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), need for assistance with personal care, and abnormal weight loss. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated Resident #23 had adequate hearing, clear speech, and impaired vision. The MDS indicated Resident #23 had a BIMS score of 15 which indicated intact cognition and only required supervision for dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #23 was always continent for urinary and bowel. Record review of a care plan with revision date of 06/19/23 indicated Resident #23 had an ADL self-care performance deficit related to impaired vision. Resident #23 was able to do most ADLs with supervision or setup assist. Intervention included needs set up for meals. During an interview on 08/29/23 at 8:41 a.m., Resident #23 said her water pitcher was never taken up by staff and washed. She said she could not remember the last time it was washed. 5. Record review of a face sheet dated 08/30/23 indicated Resident #79 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves.), contracture (reduce joint mobility and restrict activities of daily living) left and right ankle, stiffness in right and left shoulder, and need for assistance with personal care. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. The MDS indicated Resident #79 had minimal difficulty hearing, clear speech, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 65 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 adequate vision. The MDS indicated Resident #79 had a BIMS score of 11 which indicated moderate cognitive impairment and did not reject care. The MDS indicated Resident #79 required extensive assistance for bed mobility and personal hygiene, and total dependence for dressing, toilet use and bathing. The MDS indicated Resident #79 had limited range of motion bilateral upper and lower extremities. The MDS indicated Resident #79 was always incontinent of urinary and bowel. Residents Affected - Some Record review of a care plan dated 04/06/23 indicated Resident #79 had an ADL self-care performance deficit related to weakness and nerve damage related to Guillain Barre Syndrome. Intervention included 1 staff extensive participation for meals. During an interview and observation on 08/29/23 at 2:52 p.m., Resident #79 said staff do not wash her water cup or change her drinking straw. Resident #79's water cup or straw did not have any dirty substance noted. 6. Record review of a face sheet dated 08/28/23 indicated Resident #98 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), muscle weakness, slowness and poor responsiveness, limitation of activities due to disability, retention of urine, and need for assistance with personal care. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #98 was sometimes understood and usually understood others. The MDS indicated Resident #98 had adequate hearing, unclear speech, and highly impaired vision. The MDS indicated Resident #98 had a BIMS score of 05 which indicated severe cognitive impairment and required limited assistance for bathing and extensive assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #98 had an indwelling catheter and always incontinent for bowel continence. Record review of a care plan dated 08/07/23 indicated Resident #98 had urinary tract infection. He was being treated with antibiotics/contact isolation. Interventions included contact isolation for ESBL (extended spectrum beta-lactamase; It's an enzyme found in some strains of bacteria in urine and obtain and monitor lab/diagnostic work as ordered. Record review of Resident #98's consolidated physician order dated 08/07/23 indicated CONTACT ISOLATION (hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices) diagnosis ESBL (extended spectrum beta-lactamase; It's an enzyme found in some strains of bacteria)/URINE every shift. Record review of Resident #98's urine culture dated 08/16/23 indicated ESBL E. coli (Escherichia coli is a bacteria) and Serratia marcescens (can cause nosocomial outbreaks, and urinary tract and wound infections, is abundant in damp environments). This gram-negative (are among the world's most significant public health problems due to their high resistance to antibiotics) organism is an ESBL organism. During an observation on 08/28/23 at 9:43 a.m., Resident #98 had a contact isolation sign of his door. CNA A entered Resident #98's room with no PPE (Personal Protective Equipment (PPE) is specialized clothing or equipment worn by an employee for protection against infectious materials). CNA A had a bag item to provide incontinent care or bathing. CNA A was in the room for approximate 15-20 minutes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 66 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 observation on 08/28/23 at 12:51 p.m., CNA B entered Resident #98's room without donning PPE. CNA B exited Resident #98's room with gloves on then walked down the hall. During an observation on 08/28/23 at 3:27 p.m., CNA B went into Resident #98's room without PPE and rounded on resident. CNA B exited Resident #98's room without using hand gel. Residents Affected - Some During an observation on 08/28/23 at 3:39 p.m., CNA B went into Resident #98's room without donning PPE. CNA B turned the light switch on and off, leaned against Resident #98's bedside tray, placed meal tickets down and asked him what he wanted he wanted for dinner. CNA B exited Resident #98's room without using hand gel or washing hands. CNA B went into the next room to get another resident meal order. During an observation on 08/29/23 at 9:06 a.m., CNA A entered Resident #98's room without PPE. She asked him if he was finished with his breakfast tray then picked up tray and placed it on the meal cart. CNA A did not use hand gel or wash hands after touching Resident #98's breakfast tray. During an interview on 08/30/23 at 9:03 a.m., CNA A said Resident #98 was in contact isolation for something in his urine. She said she used a gown and gloves when she provided Resident #98 patient care. CNA A said she disposed of the PPE in the bins in the bathroom. She said when she provided incontinent care of Resident #32 on 08/29/23, she wiped back to front instead of front to back. CNA A said she thought she changed gloves when she was supposed to. She said dirty gloves should not be used to open doors or barrels. CNA A said proper incontinent care was important for infection control and prevent cross contamination. She said improper incontinent care could cause residents to get urinary tract infection and get confused. CNA A said she had recently completed competency check off for proper male and female perineal care. CNA A said water cups should be cleaned once a week on Fridays or when dirty. She said she did not know if they were cleaned last Friday. During an interview on 08/30/23 at 9:47 a.m., CNA B said she had been working at the facility for 3 days. She said she did not know why Resident #98 was on contact isolation. CNA B said she noticed the sign after the fact but there were no gowns in the isolation bin outside the door. She said she did not know what ESBL was off the top of her head but probably learned about it in CNA school. CNA B said she performed incontinent care and emptied Resident #98's indwelling catheter bag without proper PPE. She said no one informed her about why Resident #98 was in isolation and what PPE to wear. CNA B said she was not a new CNA but had not been checked off for competency. During an interview on 08/30/23 at 2:07 p.m., LVN D said resident water cups should probably be cleaned daily. She said she did not know what the facility's protocol or procedure was for when the cups should be cleaned. LVN D said she thought the evening CNA was responsible for taking the cups to the kitchen to be cleaned. LVN D said she normally only saw the water cups get cleaned when they got dirty from soda or coffee. She said not regularly cleaning the water cups harbored germs and could cause infections. LVN D said Resident #98 was in isolation for ESBL in his urine. She said PPE was supposed to be donned anytime you entered the room. LVN D said all staff members were responsible for wearing PPE when they entered Resident #98's room. She said she had not informed CNA B about Resident #98's contact isolation status but the sign was on the door and most staff asked before entering if they did not know. LVN D said PPE should be worn to protect yourself and not spread germs to others. She said LVNs should make sure staff were donning and doffing PPE for contact isolation. LVN D said gloves should be changed after incontinent care was provided and hands washed, or hand gel used. She said proper incontinent care protected the residents from germs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 67 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 Residents Affected - Some During an interview on 08/30/23 at 2:52 p.m., [NAME] F said CNAs picked resident's water cups once or twice a week and brought them to the kitchen. She said the kitchen staff then gave the CNAs new cups to immediate give back to the resident. [NAME] F said she did not know the exact schedule when or who brought the water cups, but the nurses should have it. During an interview on 08/31/23 at 8:20 a.m., LVN C said Resident #98 was in contact isolation for ESBL in his urine. She said gown and gloves should be used whenever you entered Resident #98's room. LVN C said nurses should ensure CNAs used the proper PPE and the DON should make sure everyone else was. She said proper use of PPE was important to prevent cross contamination. LVN C said she normally gave new CNAs report, so they knew how to take care of each resident. She said she did not know if she gave report to CNA B when she started working on the 300 hall. During an observation on 08/31/23 at 9:00 a.m., CNA B asked a dietary aide to replace a resident cup because they had dropped their lid. The dietary aide said she had to wash the new cup before she could give it to her for the resident. During an interview on 08/31/23 at 9:45 a.m., the DON said gloves should be discarded after incontinent care then hands washed, or hand gel used. The DON said dirty gloves should not be used to open a resident's door or linen barrel. She said residents should be cleaned front to back not back to front. The DON said proper perineal care was important to decrease the risk of adverse events. She said all nursing staff should ensure proper incontinent care was performed. The DON said CNAs were checked off yearly of competency which include proper male and female incontinent care. She said CNA A recently completed her competency and passed with flying colors. The DON said she was the Infection Control Preventionist. She said Resident #98 was on contact isolation for ESBL in his urine. The DON said all staff were responsible for proper isolation set up. She said LVNs was responsible for stocking the isolation supply bin and CNAs emptied the linen and trash biohazard bins in the bathroom. The DON said PPE was supposed to be used when you entered the room and provided cares. She said the facility had yearly in-services to ensure staff knew about the contact isolation policy. The DON said proper usage of PPE decreased the risk of adverse effects and spreading of germs. She said LVNs should make sure CNAs used proper PPE for contact isolation residents. The DON said managers should make sure everyone was following the contact isolation policy by doing daily rounds and check offs. She said water cups were washed twice a week by dietary. The DON said the resident's water cups were getting washed regularly. During an interview on 08/31/23 at 10:41 a.m., the Administrator said he expected CNAs to provide proper incontinent care and follow the facility's protocol. He said he expected staff to follow the isolation policy. The Administrator said the charge nurse and nursing administration should ensure the policy was being followed. He said it was important for infection control. The Administrator said water cups were washed when they were dirty. He said the CNAs should take the water cups to the kitchen to get washed. The Administrator said the charge nurses should make sure the water cups were getting washed when dirty. He said water cups should be cleaned for infection control. Record review of a facility Resident Isolation-Categories of Transmission Based Precautions revised 06/20 indicated .to ensure that transmission-based precautions are used when caring for residents with communicable disease or transmittable infections .contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .gloves are worn when entering the room .while caring for a resident, gloves are changed after having contact with infective material .gloves are removed before leaving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 68 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 Residents Affected - Some the room and hands are washed immediately .or a waterless antiseptic agent .a gown is worn for interaction that may involve contact with the resident or potentially contaminated items in the resident's environment .the facility alerts staff to the type of precaution a resident requires . Record review of a facility Perineal Care policy date revised 06/20 indicated .to maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown .put on gloves .wash pubic area .male residents .wash penis from urethral opening or tip of the penis .wash, rinse and dry buttocks and peri-anal area without contaminating perineal area .remove gloves .wash hands or use alcohol-based hand sanitizer .do not touch anything with soiled gloves after procedure .put on clean gloves .clean and return all equipment to its proper place .placed soil linen in proper container .remove gloves .wash hands . Record review of the facility's policy Blood Glucose Monitoring revised on 06/2020 indicated . VI. The blood glucose meter will be cleaned after each use as noted in the manufacturer's instructions . XV. If the blood glucose monitor is multi-patient use: A. Clean and disinfect the blood glucose machine according to the manufacturer's directions with an appropriate cleaning product. The disinfection solvent should be effective against HIV, Hepatitis C, and Hepatitis B virus . Record review of the facility's policy Infection Prevention and Control Program revised October 24, 2022, indicated .Purpose. To Ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. 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 6 of 6 residents (Resident #s 5, 81, 32, 23, 79, and 98) and 4 of 4 staff (ADON K, LVN V, CNA A, CNA B) reviewed for infection control. The facility failed to ensure ADON K cleaned the glucometer after using it on a Resident #81. The facility failed to ensure ADON K performed hand hygiene during Resident #81's medication administration. The facility failed to ensure LVN V performed hand hygiene during Resident #5's medication administration. The facility failed to ensure CNA A provided proper incontinent care to Resident #32. The facility failed to ensure Resident #23 and Resident #79's water pitchers were cleaned regularly. The facility failed to ensure CNA A and CNA B followed contact isolation guideline for Resident #98. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 69 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 Residents Affected - Some 1. During an observation on 08/29/2023 at 8:30 AM, ADON K put on gloves, took the glucometer, and went into Resident #81's room to check his blood sugar. ADON K came out of the room with her gloves still on and placed the glucometer on top of the medication cart. ADON K did not clean the glucometer. ADON K removed her gloves and did not perform hand hygiene. ADON K prepared oral medications to administer to Resident #81 without performing hand hygiene. Then, ADON K proceeded to prepare an insulin pen to administer insulin to Resident #81. ADON K did not perform hand hygiene prior to preparing the insulin. ADON K put on gloves (she did not perform hand hygiene prior to putting on gloves) and went into Resident #81's room and administered the medication. ADON K came out of Resident #81's room and removed her gloves. ADON K did not performed hand hygiene. During an interview on 08/29/2023 at 8:59 AM, ADON K said the glucometer should be cleaned after it was used on a resident. ADON K said not cleaning the glucometer after using it on a resident placed the residents at risk for cross contamination. ADON K said hand hygiene should be performed prior to preparing medications and after administering medications. ADON K said hand hygiene should be performed in between glove changes and after removing gloves. ADON K said she should have performed hand hygiene after removing her gloves and before administering medications and preparing the medications. ADON K said not performing hand hygiene appropriately placed the residents at risk for cross contamination and the spread of infection. ADON K said she did not perform hand hygiene when she should have, and she did not clean the glucometer or insulin pen because she was nervous. ADON K said the nurses were responsible for ensuring the glucometers were being cleaned and performing hand hygiene at the appropriate times. ADON K said the DON had checked her off on hand hygiene, cleaning the glucometer, and medication administration verbally and by return demonstration. 2. During an observation on 08/29/2023 at 9:19 AM, LVN V administered medications to Resident #5 via PEG tube (tube inserted in stomach used to administer feedings, liquids, and medications). LVN V put on gloves and administered valproic acid (medication used for seizures and mental conditions) via Resident #5's PEG tube. LVN V removed her gloves and went to her medication cart to obtain amiodarone (medication used to treat irregular heartbeat). LVN V did not perform hand hygiene. LVN V put on gloves and administered the amiodarone. LVN V removed her gloves and went to her medication cart to obtain donepezil (medication used to treat confusion). LVN V did not perform hand hygiene. LVN V put on gloves and administered the donepezil. LVN V removed her gloves and went to her medication cart to obtain Eliquis (medication used to thin blood). LVN V did not perform hand hygiene. LVN V put on gloves and administered the Eliquis. LVN V removed her gloves and went to her medication cart to obtain risperidone (medication used to treat mental/mood disorders). LVN V did not perform hand hygiene. LVN V put on gloves and administered the risperidone. LVN V removed her gloves and went to her medication cart to obtain levothyroxine (medication used to treat low thyroid). LVN V did not perform hand hygiene. LVN V put on gloves and administered the levothyroxine. LVN V removed her gloves and did not perform hand hygiene. During an interview on 08/29/2023 at 10:02 AM, LVN V said she was responsible for ensuring hand hygiene was performed. LVN V said hand hygiene should be performed prior to and after the administration of medications. LVN V said hand hygiene should be performed between gloves changes and after glove removal. LVN V said she had not performed hand hygiene adequately because she was nervous. LVN V said either the DON or ADON O had checked her off on hand hygiene and medication administration. LVN V said not performing hand hygiene appropriately could result in the transfer of infections. During an interview on 08/30/2023 at 4:19 PM, ADON O said the policy was to clean the glucometer after every use. ADON O said the nurses were responsible for ensuring the glucometers were cleaned after each use. ADON O said it was important for the glucometers to be cleaned after each use for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 70 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 Residents Affected - Some infection control. ADON O said not cleaning the glucometers after each use could result in another resident getting a blood-borne pathogen. ADON O said hand hygiene should be performed after glove removal and between gloves changed. ADON O said it was important to perform hand hygiene to decrease cross contamination. ADON O said the nurses were responsible for ensuring hand hygiene was performed adequately. ADON O said not performing hand hygiene adequately could result in bacteria being passed on and cross contamination. ADON O said competency checks were done upon hire and annually, and more frequently if needed. During an interview on 08/30/2023 4:50 PM, the Administrator said the glucometers should be wiped down after each resident. The Administrator said the charge nurse was responsible for ensuring this was done. The Administrator said it was important for the glucometers to be cleaned after each resident for infection control. The Administrator said hand hygiene should be performed after glove removal and between glove changes. The Administrator said the charge nurses were responsible for ensuring hand hygiene was performed adequately. The Administrator said it was important for hand hygiene to be performed adequately for infection control. During an interview on 08/30/2023 at 5:22 PM, the DON said the nurses were responsible for ensuring the glucometer was sanitized between patients. The DON said it was important for the glucometer to be sanitized to decrease the risk of adverse events. The DON said hand hygiene should be performed before and between glove changes. The DON said it was important for hand hygiene to be performed to decrease the spread of bacteria and germs. The DON said the staff was responsible for performing hand hygiene and sanitizing the glucometers. The DON said competency checks were performed upon hire and yearly on the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 71 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0908 Keep all essential equipment working safely. 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 review, the facility failed to ensure all patient care equipment was in safe operating condition for 1 of 1 resident (Resident#14) reviewed safe, functional equipment. Residents Affected - Few The facility failed to ensure Resident #14 had an armrest cushion and secured side panel of her wheelchair. This failure could place residents at risk for skin issues, discomfort, and falls. Findings included: 1. Record review of a face sheet dated 08/30/23 indicated Resident #14 was a [AGE] year-old female and admitted on [DATE] with diagnoses including repeated falls, age-related physical debility (weakness or feebleness), lack of coordination and unsteadiness on feet. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #14 was understood and understood others. The MDS indicated Resident #14 had adequate hearing, clear speech, and impaired vision with corrective lenses. The MDS indicated Resident #14 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #14 required limited assistance for bed mobility, and total dependence for toilet use, personal hygiene, and bathing. The MDS indicated Resident #14 used a walker and wheelchair as a mobility device. Record review of a care plan revised date 06/19/19 indicated Resident #14 had a self-care performance deficit related to weakness and debility. Interventions included mobility: Resident #14 used wheelchair for mobility and can self-propel short distances. During an interview and observation on 08/28/23 at 11:25 a.m., Resident #14 was sitting in her recliner in the room. Resident #14 said her only complaint was her wheelchair arm was missing a cushion and loose. She said without the arm cushion, it was scratching her. Resident #14 said it had been broken for a while. She said staff knew about the arm cushion missing. Resident #14's wheelchair had no arm cushion on the right side and the side panel was loose. During an interview on 08/30/23 at 9:03 a.m., CNA A said Resident #14 told her about the wheelchair being broken. She said Resident #14 mentioned telling her family about the issue. CNA A said she did notice this week when she gave Resident #14 a shower the wheelchair had some issues. She said Resident #14 was at risk for falls because she used the wheelchair for mobility. CNA A said she did not know who was responsible for the maintenance of resident's wheelchairs. During an interview on 08/30/23 at 2:09 p.m., LVN D said Resident #14 used her walker more than her wheelchair for mobility. She said Resident #14 used the wheelchair for in the shower or when she went out on pass. LVN D said maintenance was responsible for resident's wheelchairs. She said Resident #14 having an unsafe wheelchair placed her at risk for injuries. During an interview on 08/30/23 at 2:50 p.m., the Maintenance Director said he did not know about Resident #14 wheelchair issues. He said staff were supposed to place maintenance issue in the binder and he also like staff to verbally tell him (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 72 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/31/23 at 8:20 a.m., LVN C said she had not noticed Resident #14's wheelchair issues. She said maintenance was responsible for resident's wheelchairs. LVN C said Resident #14 was at risk for falls and skin breakdown due to her wheelchair arm not having a cushion and loose side. During an interview on 08/31/23 at 9:45 a.m., the DON said who ever found the maintenance issue should place it in the requisition book. She said issues with wheelchairs should be reported to maintenance to see if it can be fixed but then reported to the DON and ADM. The DON said maintenance repair request should be placed in binder as soon as possible. She Resident #14 was at risk for adverse effects such as injuries due to her mobility device having issues. During an interview on 08/31/23 at 10:41 a.m., the ADM said the maintenance director was responsible for the upkeep of resident assistive devices such as wheelchairs. He said staff should notify maintenance and place a work order in the maintenance book. The ADM said Resident #14 was at risk for skin breakdown and tears using a wheelchair with no arm cushion and loose side panel. Record review of the 300-hall repair requisition book dated 05/23-08/23 did not reveal a work order for Resident #14's wheelchair. Record review of a facility Resident Rights-Accommodation of Needs policy revised date 08/20 indicated .to ensure that the facility provides an .services that meet residents' individual needs .the facility's environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being .providing access to assistive devices . Record review of a facility Maintenance Services policy revised date 08/20 indicated .to protect the health and safety of residents .the maintenance department maintains all areas of the building, grounds, and equipment .the Maintenance department is responsible for .and equipment in a safe and operable manner at all times .maintaining all mechanical, electrical, and patient care equipment in safe operating conditions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 73 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0926 Have policies on smoking. 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 follow their own established smoking policy for 1 of 3 residents (Resident #61) reviewed for smoking. Residents Affected - Few The facility failed to ensure Resident #61 followed the facility's policy on smoking. the did not have a lighter and cigarettes on his bedside table. This failure could place residents at risk of unsafe smoking and injury. Findings included: Record review of Resident #61's face sheet, dated 09/05/23 indicated Resident #61 was an [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), diabetes (a condition that happens when your blood sugar (glucose) is too high) and seizures (when too many of your brain cells become excited at the same time). Record review of Resident #61's quarterly MDS assessment, dated 08/04/23, indicated Resident #61 was understood and understood others. Resident #61's BIMs score was 14, which indicated he was cognitively intact. Resident #61 required extensive assist with bathing, and limited assist with eating and independent with toileting, personal hygiene, transfer, dressing, and bed mobility. Record review of Resident #61's comprehensive care plan, dated 06/26/23 indicated Resident #61 used tobacco products. The interventions of the care plan were for staff to provide Resident #61 with the smoking policy and potential consequences of noncompliance, to keep all his smoking supplies in a box kept at the nurses' station, to return his smoking supplies at the end of each smoke break, and only smoke during the designated times determined by facility staff. Record review of Resident #61's Smoking assessment, dated 07/10/23, revealed Resident #61 was safe to smoke with minimal supervision. During an observation and interview on 08/28/23 at 9:32 a.m., revealed Resident #61 had a pack of cigarettes and a lighter on his bedside table. Resident #61 said he and his family member smoked last night after smoking hours and those cigarettes and lighter were from then. Resident #61 said he was going to turn them in this morning (08/28/23) when he went out to smoke but missed the allotted smoking time. Resident #61 said he knew he was not supposed to have cigarettes or lighters in his room. During an observation and interview on 08/28/23 at 9:49 a.m., CNA Q went into Resident #61's room and saw the cigarettes and lighter sitting on his bedside table. She said the floor tech took the residents to smoke during the designated smoking times and they were supposed to ensure they received all smoking paraphernalia back. CNA Q said residents were not supposed to have cigarettes or lighters in their room for safety issues. CNA Q said she would report the resident to her charge nurse about the cigarettes and lighter. During an interview on 08/28/23 at 9:53 a.m., Floor Tech Z said the floor techs took the residents to smoke during the designated smoking times. He said Resident #61 did not come out for the 9:30am (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 74 of 75 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few smoke break today (08/28/23). He said residents were not supposed to keep cigarettes or lighters for safety reasons. During an observation and interview on 08/29/23 at 8:41 a.m., LVN S said she became aware Resident #61 had some cigarettes and a lighter on his bedside table about 1pm on yesterday (08/28/23). She said when she went into his room, he only had an empty cigarette box lying on his bedside table. LVN S said she talked to Resident #61 about turning in his cigarettes and lighter to the floor techs and he voiced understanding. She said residents should not have cigarettes or lighters in their room because of safety concerns. During an interview on 08/30/23 at 4:41 p.m., ADON H said she expected Resident #61 to follow the smoking policy. She said Resident #61 and his family had been talked too about following the smoking policy. ADON H said when residents have cigarettes or lighters in their room it could lead to safety issues for everyone. During an interview on 08/30/23 at 4:57 p.m., the DON said she expected Resident #61 to follow the smoking rules and he was aware of the smoking policy. She said the floor techs were responsible to ensure residents returned any paraphernalia they had during designated smoking times. The DON said cigarettes and lighters were locked up for safety. During an interview on 08/30/23 at 5:24 p.m., the Administrator said he had talked with Resident #61 about the smoking policy, and he was aware of the consequences of not following the smoking policy. He said the floor techs were responsible for taken the residentsto smoke and the Maintenance Supervisor was the overseer. He said cigarettes and lighters should be locked up after each smoking time for the safety of all residents. Record review of the facility policy for Smoking revised 06/2020, indicated, purpose: to respect resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers. Policy: Smoking is not allowed anywhere inside the facility, smoking is only permitted in areas designated by the facility safety committee, residents who were not able to smoke safely will be accomplished by facility staff while smoking. Procedure: residents will be provided with a copy of this policy during the admission process, the risk of continued smoking will be discussed with the resident/ family and/or representative at the time of admission, all smoking material will be stored in a secure area to ensure they were kept safe, all smoking sessions will be supervised by a facility staff member. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675133 If continuation sheet Page 75 of 75