Health inspection·December 20, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Record review of Resident #45's dated 12/20/23, indicated an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #45's diagnoses included dementia (memory loss), essential hypertension (high blood pressure), and chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #45's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #45 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS assessment indicated he had received an anticoagulant medication. The MDS assessment did not indicate Resident #45 had received an antiplatelet medication. Record review of Resident #45's comprehensive care plan dated 01/10/23, indicated he was on anticoagulant therapy with interventions to monitor for anticoagulant complications such as bruising, blood-tinged urine, and dark or bright red stools. Record review of Resident #45's order summary report dated 12/20/23, indicated he had an order for Aspirin 81mg one tablet by mouth once a day with a start date of 08/02/23. Resident #45 did not have an order for an anticoagulant medication. Record review of Resident #45's medication administration record for the month of December 2023, indicated he had received aspirin 81mg daily. The medication administration record did not indicate he had received any anticoagulant medication. 5. Record review of Resident #18's face sheet dated 12/20/23, indicated an [AGE] year old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident ##18's diagnoses included parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of the bones wears down), and heart failure (a chronic condition in which the heart does not pump blood as well as it should). Record review of Resident #18's annual MDS assessment dated [DATE], she was able to make herself understood and usually understood others. The MDS assessment indicated Resident #18 had a BIMS score of 8, indicating her cognition was moderately impaired. The MDS assessment indicated Resident #18 had received anticoagulant and antiplatelet medications within the 7-day look-back period. Record review of Resident #18's comprehensive care plan dated 04/16/21 and revised on 12/13/21, indicated she was on anticoagulant therapy. The care plan interventions included daily skin inspection and report any abnormalities to the nurse. Record review of Resident #18's order summary report dated 12/20/23, indicated she had the following orders: *Aspirin 81mg one tablet by mouth daily with a start date of 04/11/22. *Clopidogrel (antiplatelet medication) 75mg one tablet by mouth daily with a start date of 01/26/21. Resident #18 did not have any orders for anticoagulant medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 2 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #18's MAR for December 2023, indicated she had been receiving aspirin 81 mg and clopidogrel 75mg daily. The medication administration record did not indicate she had received any anticoagulant medication. During an interview on 12/20/23 at 1:07 PM, MDS Coordinator A stated she had been trained on 10/01/2023 for recent changes on the MDS from corporate. MDS coordinator A stated staff was informed that aspirin was now be listed as an anticoagulant. MDS coordinator stated she is responsible for completing her part of the MDS and the DON was responsible for signing off on the MDS that it was completed. The MDS coordinator stated that corporate audits the MDS assessments quarterly for accuracy. The MDS coordinator stated the importance of making sure the MDS was correct was because medications had different reactions and they were considered high risk drug classes. If medications were not coded correctly the resident could have had an adverse reaction to the medication or a change in condition. During an interview on 12/20/23 at 1:49 PM, the DON stated she was responsible for making sure the MDS assessment was correct. The DON stated that the MDS nurses had informed her that aspirin was considered an anticoagulant after attending the corporate meeting on 10/01/23. The DON stated the importance of making sure the MDS assessment was correct was that the facility was aware of the resident's health and their level of care. During an interview on 12/20/23 at 3:12 PM, the ADM stated he expected the MDS assessment to be completed accurately. The ADM stated the MDS coordinators were responsible for making sure the MDS assessment was accurate, and it could affect the residents and it could impact drug interactions or proper resident care if not filled out correctly. During an interview on 12/19/23 at 4:06 PM, the Regional Compliance Nurse said they did not have a policy on MDS assessment or accuracy. The Regional Compliance Nurse said they followed the RAI (Resident Assessment Instrument) manual. The Regional Compliance Nurse said Residents #43, #45, and #18 were not receiving a true anticoagulant medication and all were taking aspirin. Record review of section N of the RAI manual on 12/20/23, indicated .Anticoagulant (e.g. warfarin, heparin, or low molecular weight heparin): check if an anticoagulant was taken by the resident at anytime of the 7-day look-back period . The RAI manual indicated .Antiplatelet: check if an antiplatelet medication (e.g. aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7- day look back observation period . Based on interview and record review, the facility failed to ensure an accurate MDS was completed for 5 of 19 residents reviewed for MDS assessment accuracy. (Resident #49, #39, #43, #45, and #18). 1. The facility failed to accurately reflect Resident #49's weight loss on the MDS assessment. 2. The facility inaccurately coded Residents #39, #43, #45, and #18 as having received an anticoagulant medication. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 3 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. Record review of Resident #49 face sheet, dated 12/20/23, indicated Resident #49 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included unspecified protein-calorie malnutrition, iron deficiency anemia unspecified, muscle weakness, Hypothyroidism (thyroid gland does not produce enough thyroid hormone, unspecified lack of coordination, unspecified dementia, unspecified severity without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and essential hypertension (high blood pressure). Record review of the admission MDS assessment, dated 12/08/23, indicated Resident #49 rarely made herself-understood, and understood others. The assessment indicated a BIMS score of 11 which indicated moderately impairment cognition. The assessment indicated Resident #49 functional status indicated Resident #49 required supervision or touching assistance with eating and oral hygiene: Substantial/maximal assistance with bed mobility, transfers, dressing, and toilet use. Resident #49 MDS was not coded for weight loss. Record Review of the comprehensive care plan dated on revised on 10/25/23 indicated Resident #49 required antidepressant medication. The care plan interventions included, Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Resident #49 was not care planned for weight loss. Record Review of the progress note dated 10/26/23, indicated on Weights: October-149.8 September-153 3/30/23: 162.8, 8% WT Loss times 6 months, 6.8% times 3 months body mass index: 25.7 diet prescription, diagnosis, meds, reviewed. orders noted for 03, regular diet with red glass program. skin assessment: no wounds noted. staff report usual oral by mouth intake often <75%, and that resident has been more sleepy than usual with feelings of the blues, medical doctor was notified, and medication changed. observed resident during a lunch meal in dining room with director present. res stated her appetite was lousy. additional food preferences were noted at that time and given to dietary. resident receiving super pudding per request. Director and resident agreeable to receiving 2.0 supplement. goal: adequate po intake to meet estimated nutritional needs, maintain calculated body weight within 4% x next 30 days recommend: (1.) super pudding with l & s (2.) 2.0 supplement 2 oz 4 times a day (3). continue to monitor weights (4). follow as needed. During an interview on 12/20/23 at 1:28 p.m., the MDS coordinator stated she's had been the MDS coordinator since 2006. The MDS Coordinator stated she was responsible for Resident #49 MDS. The MDS Coordinator stated Resident #49 did triggered for weight loss. The MDS Coordinator stated she did not know why weight loss was not coded on Resident #49 MDS. The MDS coordinator stated she did not know why weight loss was not on Resident #49 MDS. The MDS coordinator stated, I was missed it. The MDS Coordinator stated she was responsible for ensuring Resident #49 was coded for weight loss. The MDS Coordinator stated she was overseen by the Administrator, Corporate Reimbursement Nurse, and the Corporate supervisor. The MDS Coordinator stated not coding Resident #49 MDS for weight loss was a risk , but she did not see Resident#49 until she did the quarterly MDS, so she may have missed it. The MDS coordinator stated she should have codded weight loss on the MDS, but she did not. The MDS Coordinator stated she monitored the documentation in PCC for coding the residents. The MDS Coordinator stated she also discussed the residents' MDS during the morning meetings. The MDS Coordinator stated Resident #49 had weight loss intervention in place and was taking weight loss medicine, but the MDS did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 4 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not reflect this. The MDS Coordinator stated it was important to ensure the Resident #49 MDS was coded for weight loss to further identify weight loss for Resident #49. During an interview on 12/20/23 at 1:48 p.m., the ADON stated she had been the ADON since 8/30/21. The ADON stated Resident #49 had been put on two appetites stimulants for weight loss. The ADON stated she was overseen at the facility by the DON. The ADON stated she did not know why malnutrition and weight loss was not Resident #49's MDS. The ADON stated the facility incorporated the glass program which informed staff that residents on the glass program needed some assistance with eating and were at risk of weight loss. The ADON stated she monitored the residents for weight loss by looking at them and talking to dietary staff or by looking at their plates, or if the residents liked the first plate food, she may request a second plate for the resident. During an interview on 12/20/23 at 2:00 p.m., the DON stated she had been the DON at the facility for 1 year. The DON stated she was responsible for overseeing the ADON and MDS coordinators. The DON stated she monitored the MDS during the facility's SOC meetings Standards of care. The DON stated that weight loss and malnutrition were important to ensure that the resident received adequate nutrition to keep her strong. During an interview on 12/20/23 at 2:22 p.m., the Administrator stated he had been the administrator for 2 years. The Administrator stated he did not monitor the MDS. The Administrator stated that the nursing staff worked together to ensure that MDS were coded. The Administrator stated at the morning care plan meeting that the MDS coordinator took notes and transferred the updated information to the MDS. The Administrator stated he relied on the nursing administration and MDS staff to ensure that MDS were coded correctly. The Administrator stated he expected the MDS to be accurate for the residents and for the MDS coordinator and ADON to communicate any changes with the residents during morning meetings. The Administrator stated it was important to ensure that the MDS were coded for weight loss in order to appropriately respond to the weight loss and ensure the resident can gain weight if that is desirable. Record Review of Comprehensive Care Planning policy undated revealed, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs . When developing the comprehensive care plan, facility staff will, at a minimum, use the minimum data set(MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 5 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 - Few 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 observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 19 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1's comprehensive care plan addressed that she received oxygen. This failure could place residents at risk of not receiving necessary medications and services. Findings included: Record review of Resident #1's face sheet dated 12/20/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), protein-calorie malnutrition (inadequate protein intake), and essential hypertension (high blood pressure). Record review of Resident #1 quarterly MDS assessment dated [DATE], indicated Resident #1 was rarely/never understood and rarely/never understood others. The MDS assessment indicated Resident #1 cognition was severely impaired. Resident #1 was totally dependent on staff with all ADLs. The MDS assessment indicated Resident #1 had received oxygen therapy within the last 14 days of the look back period. Record review of Resident #1's comprehensive care plan dated 11/07/23 did not indicate Resident #1 was receiving oxygen therapy. Record review of Resident #1's order summary report dated 12/20/23, indicated resident had an order for oxygen as needed to keep oxygen saturation greater than 90% with a start date of 09/29/23. Record review of Resident #1's treatment administration record for December 2023, indicated oxygen as needed to keep oxygen saturations greater than 90% was being documented as being administered daily. During an observation on 12/18/23 at 11:37 AM, Resident #1 was lying in bed and receiving oxygen at 2.5 liters per minute via nasal cannula. During an observation on 12/19/23 at 10:43 AM, Resident #1 was lying in bed and receiving oxygen at 2.5 liters per minute via nasal cannula. During an observation on 12/20/23 at 08:46 AM, Resident #1 was asleep in her bed and was receiving oxygen at 2.5 liters per minute via nasal cannula. During an interview and record review on 12/20/23 at 1:43 PM, LVN D said Resident #1's care plan should have indicated she received oxygen so everyone that cared for her would know she had oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 6 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 - Few LVN D said the MDS Coordinators were responsible for updating the care plan. LVN D reviewed Resident #1's care plan and said Resident #1's oxygen was not care planned. During an interview on 12/20/23 at 1:56 PM, MDS Coordinator B said they were responsible for the comprehensive and quarterly care plans. MDS Coordinator B said the ADON and DON were responsible for the acute care plans. MDS Coordinator B said Resident #1's oxygen should have been care planned so nurses and aides were aware she was on oxygen. MDS Coordinator B said when she did her quarterly or annual assessments, she would then update the care plans. MDS Coordinator B said if the nurses were signing off on the MAR or TAR then Resident #1 was receiving her oxygen. During an interview on 12/20/23 at 2:17 PM, the ADON said Resident #1's oxygen should have been on her comprehensive care plan as it was part of her medical condition. The ADON said the MDS Coordinators were responsible for updating the care plans. During an interview on 12/20/23 at 2:39 PM, the DON said Resident #1's oxygen should have been care planned. The DON said the care plans showed what they were doing, why they were doing it, and what their goals were. The DON said by not care planning Resident #1 oxygen, it could be missed. The DON said it was the MDS Coordinators responsibility to update the care plans for all chronic conditions. During an interview on 12/20/23 at 3:01 PM, the Administrator said he expected Resident #1's care plan to indicate she was receiving oxygen. He said the care plan indicated what the residents' needs were so they could properly take care of them. The Administrator said the MDS Coordinators were responsible for updating the comprehensive care plans with their assessments and the ADON and DON were responsible for the acute care plans. The Administrator said since Resident #1's oxygen was not care planned they cannot ensure she was getting the oxygen she required. Record review of the facility's undated policy titled Comprehensive Care Planning indicated . The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following .the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 7 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 observations, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for 1 of 67 residents (Resident #49) reviewed for comprehensive care plans. The facility failed to ensure Resident #49's care plan was updated to indicate weight loss. These failures could place residents at increased risk of not having their individual needs met and a decreased quality of life. The findings included: Record review of Resident #49 face sheet, dated 12/20/23, indicated Resident #49 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included unspecified protein-calorie malnutrition, iron deficiency anemia unspecified, muscle weakness, Hypothyroidism (thyroid gland does not produce enough thyroid hormone, unspecified lack of coordination, unspecified dementia, unspecified severity without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and essential hypertension (high blood pressure). Record review of the admission MDS assessment, dated 12/08/23, indicated Resident #49 rarely made herself-understood, and understood others. The assessment indicated a BIMS score of 11 which indicated moderately impairment cognition. The assessment indicated Resident #49 functional status indicated Resident #49 required supervision or touching assistance with eating and oral hygiene: Substantial/maximal assistance with bed mobility, transfers, dressing, and toilet use. Resident #49 MDS was not coded for weight loss. Record Review of the comprehensive care plan dated on revised on 10/25/23 indicated Resident #49 required antidepressant medication. The care plan interventions included, Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Resident #49 was not care planned for weight loss. Record Review of the progress note dated 10/26/23, indicated on Weights: October-149.8 September-153 3/30/23: 162.8, 8% WT Loss times 6 months, 6.8% times 3 months body mass index: 25.7 diet prescription, diagnosis, meds, reviewed. orders noted for 03, regular diet with red glass program. skin assessment: no wounds noted. staff report usual oral by mouth intake often &lt;75%, and that resident has been more sleepy than usual with feelings of the blues, medical doctor was notified, and medication changed. observed resident during a lunch meal in dining room with director present. res stated her appetite was lousy. additional food preferences were noted at that time and given to dietary. resident receiving super pudding per request. Director and resident agreeable to receiving 2.0 supplement. goal: adequate po intake to meet estimated nutritional needs, maintain calculated body weight within 4% x next 30 days recommend: (1.) super pudding with l & s (2.) 2.0 supplement 2 oz 4 times a day (3). continue to monitor weights (4). follow as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 8 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 During an interview on 12/20/23 at 1:28 p.m., the MDS coordinator stated she's had been the MDS coordinator since 2006. The MDS Coordinator stated Resident #49 triggered for weight loss. The MDS Coordinator stated she was overseen by the Administrator, Corporate Reimbursement Nurse, and the Corporate supervisor. The MDS Coordinator stated the ADON did not care plan the weight loss. The MDS Coordinator stated, Weight loss was not care planned because she did not catch it. The MDS Coordinator stated Resident #49 had weight loss intervention in place and was taking weight loss medicine. During an interview on 12/20/23 at 1:48 p.m., the ADON stated she had been the ADON since 8/30/21. The ADON stated she and the DON was responsible for coding weight loss on Resident #49 Care plan. The ADON stated Resident #49 had been put on two appetites stimulants for weight loss. The ADON stated she malnutrition and weight loss should have been on Resident #49 care plan. The ADON stated she was overseen at the facility by the DON. The ADON stated she did not know why malnutrition and weight loss was not care planned on Resident #49 care plan. The ADON stated residents could be care planned for by anyone in the facility. The ADON stated the DON, treatment nurses, nurses also care planned for the residents. The ADON stated not care planning malnutrition and weight loss could have led to a multitude of issues; The ADON stated the risks for not care planning malnutrition and weight loss were skin issues, dehydration. The ADON stated the facility incorporated the glass program which informed staff that residents on the glass program needed some assistance with eating and were at risk of weight loss. The ADON stated she monitored the residents for weight loss by looking at them and talking to dietary staff or by looking at their plates, or if the residents liked the first plate food, she may request a second plate for the resident. During an interview on 12/20/23 at 2:00 p.m., the DON stated she had been the DON at the facility for 1 year. The DON stated she was responsible for overseeing the ADON and MDS coordinators. The DON stated she monitored the care plans during the facility's SOC meetings Standards of care. The DON stated that weight loss and malnutrition were important in the care plan to ensure that the resident received adequate nutrition to keep her strong. During an interview on 12/20/23 at 2:22 p.m., the Administrator stated he had been the administrator for 2 years. The Administrator stated he did not monitor the care plans. The Administrator stated that the nursing staff worked together to ensure care plans were care planned. The Administrator stated the acute care planning was the responsibility of the ADON. The Administrator stated he relied on the nursing administration and MDS staff to ensure care plans were accurate. The Administrator stated he expected the care plan to be accurate for the residents and for the MDS coordinator and ADON to communicate any changes with the residents during morning meetings. The Administrator stated it was important to ensure the care plans were care planned correctly for weight loss in order to appropriately respond to the weight loss and ensure the resident can gain weight if that is desirable. The Administrator stated the care plan must be accurate and up to date. Record Review of Comprehensive Care Planning policy undated revealed, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs . When developing the comprehensive care plan, facility staff will, at a minimum, use the minimum data set(MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 9 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for enteral nutrition (Resident #48). The facility failed to ensure LVN F rinsed Resident #48's gastrostomy tube (feeding tube inserted in stomach used for feeding and medication administration) syringe after she administered a medication. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk for gastric infections. Findings included: Record review of Resident #48's face sheet dated 12/20/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #48's diagnoses included Parkinson's disease (a disorder oof the central nervous system that affects movement, often including tremors), Meniere's disease (inner ear disorder that causes episodes of dizziness), gastrostomy, and dysphagia (difficulty swallowing). Record review of Resident #48's quarterly MDS assessment dated [DATE], indicated he rarely/never made himself understood and was able to understand others. The MDS assessment indicated his cognition was severely impaired. The MDS assessment indicated Resident #48 was dependent on staff for all ADLs and had a feeding tube. Record review of Resident #48's comprehensive care plan dated 08/02/22, indicated he required a feeding tube with a goal that Resident #48 would remain free of side effects or complications related to the tube feeding through the review date. Record review of Resident #48's order summary report dated 12/20/23, indicated he had an order for carbidopa-levodopa 25-100mg give 2 tablets via gastrostomy tube three times a day for Parkinson's disease. Record review of Resident # 48's treatment administration record for the month of December 2023, indicated he had been receiving carbidopa-levodopa 25-100mg 2 tabs three times a day via his gastrostomy tube. During an observation on 12/20/23 at 3:20 PM, LVN F administered Resident #48's carbidopa-levodopa via his gastrostomy tube using a 60 ml syringe. After administration of medication, LVN F placed the syringe back in the packet without cleaning it. During an interview on 12/20/23 at 11:06 AM, LVN F said she was unsure if she had to rinse the syringe after she administered medication. LVN F said she would assume medication could still be left in the syringe and go into the next medication pass if the syringe was not cleaned. LVN F said she was responsible for ensuring the syringe was cleaned after each use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 10 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/20/23 at 2:17 PM, the ADON said LVN F should have rinsed the syringe after administering the medication to Resident #48. The ADON said by not cleaning the syringe medication particles from a previous medication could have been left in the syringe and it was not sanitary. The ADON said the nurse was responsible for ensuring she cleaned the syringe after each use. During an interview on 12/20/23 at 2:39 PM, the DON said she expected the syringe to be cleaned after each use and failure to do so was an infection control issue. The DON said the nurse administrating the medication was responsible for ensuring the syringe is cleaned after each use. During an interview on 12/20/23 at 3:01 PM, the Administrator said he was unsure of the risks for not cleaning the syringe after use, but he believed the resident could still get medication from the previous dose. The Administrator said the syringe should have been cleaned after every use. He said he was unsure of the protocols. The Administrator said the nurse that used it was responsible for ensuring they cleaned the syringe after each use. Record review of the facility's policy and procedure Enteral Medication Administration revised 01/25/13, indicated . 12. Change the medication syringe as directed by manufacturer's label. If the syringe is used for 24 hours, clean after each use . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 11 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 respiratory care was provided with professional standards of practice for 1 of 4 resident reviewed for quality of care. (Resident #1) Residents Affected - Few The facility failed to obtain the amount of oxygen to be administered to Resident #1. This failure could place residents who receive respiratory care at risk for developing respiratory complications. Findings included: Record review of Resident #1's face sheet dated 12/20/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), protein-calorie malnutrition (inadequate protein intake), and essential hypertension (high blood pressure). Record review of Resident #1 quarterly MDS assessment dated [DATE], indicated Resident #1 was rarely/never understood and rarely/never understood others. The MDS assessment indicated Resident #1 cognition was severely impaired. Resident #1 was totally dependent on staff with all ADLs. The MDS assessment indicated Resident #1 had received oxygen therapy within the last 14 days of the look back period. Record review of Resident #1's comprehensive care plan dated 11/07/23 did not indicate Resident #1 was receiving oxygen therapy. Record review of Resident #1's order summary report dated 12/20/23, indicated resident had an order for oxygen as needed to keep oxygen saturation greater than 90% with a start date of 09/29/23. The oxygen order did not indicate the rate the oxygen should have been administered to Resident #1. Record review of Resident #1's treatment administration record for December 2023, indicated oxygen as needed to keep oxygen saturations greater than 90% was being documented as being administered daily. The order did not have the rate the oxygen should have been administered to Resident #1. During an observation on 12/18/23 at 11:37 AM, Resident #1 was lying in bed and receiving oxygen at 2.5 liters per minute via nasal cannula. During an observation on 12/19/23 at 10:43 AM, Resident #1 was lying in bed and receiving oxygen at 2.5 liters per minute via nasal cannula. During an observation on 12/20/23 at 08:46 AM, Resident #1 was asleep in her bed and was receiving oxygen at 2.5 liters per minute via nasal cannula. Record review of Resident #1's treatment administration record for December 2023, indicated oxygen as needed to keep oxygen saturations greater than 90% was being documented as being administered daily. The order did not have the rate the oxygen should have been administered to Resident #1. During an interview and observation on 12/20/23 at 1:43 PM, LVN D said she expected the oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 12 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 - Few order to have how many liters per minute the oxygen should be administered. LVN D said by not having the ordered rate on the order anyone could put the oxygen at any rate which could cause Resident #1 to receive too much or not enough oxygen. LVN D reviewed Resident #1's order and said she could not tell the surveyor how much Resident #1's oxygen rate should have been set at. LVN D said the nurses were responsible for ensuring when they obtained an oxygen order to include the rate to be administered. LVN D said the ADON was responsible for reviewing the orders and ensuring they were transcribed correctly. During an interview on 12/20/23 at 1:56 PM, MDS Coordinator B said she did not input the order for Resident #1 as she only tweaked it to ensure the nurses were signing off on the MAR and why her name was showing as she had transcribed the order. The MDS Coordinator B said Resident #1's oxygen order should have been clarified to indicate how much oxygen to administer. The MDS Coordinator B said the nurse was responsible for obtaining a clarification order and the DON was responsible for following up on the order. During an interview on 12/20/23 at 2:17 PM, the ADON said an oxygen order not having the ordered rate was a problem. The ADON said they did not need to have a physician's order for oxygen set at 2 liters per minute, but an order was required for anything above 2 liters. The ADON said the nurse should not have taken an incomplete order and should have had questioned the doctor. The ADON said by not having an ordered rate on Resident #1's oxygen order could cause Resident #1 to receive too much or not enough oxygen. The ADON said the DON and herself reviewed orders after their morning clinical meeting. The ADON said she was unsure of how Resident #1's oxygen order was missed. During an interview on 12/20/23 at 2:39 PM, the DON said she expected an oxygen order to be specific on how many liters the resident should be receiving and if it was as needed or continuous. The DON said by not having the specific rate on the order it gave the nurses free range and could cause Resident #1 to receive too much or not enough oxygen. The DON said the nurses and nursing administration were responsible for ensuring the orders were transcribed correctly. The DON said she reviewed orders daily to ensure orders have parameters in place and Resident #1's oxygen order must have been missed. During an interview on 12/20/23 at 3:01 PM, the Administrator said he expected the oxygen orders to have the designated amount of oxygen to be administered and to indicate if it was as needed or continuous. The Administrator said he was unsure of the risks for not have the rate of oxygen to be administered but he believed they would not receive enough oxygen, and this cause their oxygen saturations to drop. The Administrator said they nurse who received the order was responsible for ensuring the order was transcribed correctly. The Administrator said he was unsure if nursing management reviewed the physician's orders. Record review of the facility's policy titled Oxygen Administration revised February 13, 2007, indicated .Oxygen therapy includes the administration of oxygen in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac disease . The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 13 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 0760 Ensure that residents are free from significant medication errors. 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 residents were free of significant medication errors for 1 of 6 residents reviewed for pharmacy services. (Resident #54) Residents Affected - Few The facility failed to ensure MA G administered Resident #54's nifedipine (blood pressure medication) extended release correctly. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #54's face sheet dated 05/26/22, indicated she was admitted to the facility on [DATE] with diagnoses included cerebral infarction (stroke), depression, essential hypertension (high blood pressure), and dysphagia (difficulty swallowing). Record review of Resident #54's quarterly MDS assessment dated [DATE], indicated she was rarely/never understood and sometimes understood others. The MDS assessment indicated Resident #54's cognition was moderately impaired. Record review of Resident #54's comprehensive care plan dated 05/27/23, indicated she had hypertension with interventions to give antihypertensive medication as ordered and to monitor side effects such as orthostatic hypotension (blood pressure drops when standing or sitting) and increased heart rate. Record review of Resident #54's order summary report dated 12/20/23, indicated she had an order for nifedipine ER 60mg one tablet one tablet a day for essential hypertension with a start date of 09/15/22. During an observation on 12/19/23 at 08:37 AM, MA G administered all Resident #54's medications crushed and mixed with pudding. Nifedipine 60mg ER tablet was included in her crushed medications. During an interview on 12/19/23 at 3:02 PM, MA G said if a medication indicated ER, it meant the medication was extended release and they were not to be crushed. MA G said she did not notice Resident #54's nifedipine was extended release and should have not been crushed as it would not have had the same effect. MA G said she was responsible for ensuring the medications were given appropriately. During an interview on 12/20/23 at 11:09 AM, RN E said medications that have ER should not be crushed as they were extended-release tablets, and the medication was released over time. RN E said MA G crushing Resident #54's nifedipine ER tablet put her at risk for her blood pressure dropping. RN E said MA G was responsible for ensuring medications were given correctly. During an interview on 12/20/23 at 2:17 PM, the ADON said medications that were extended release were not to be crushed and a massive dose could be administered at once if they were given crushed. The ADON said the residents blood pressure could bottom out and then be sky high for the next dose. The ADON said MA G should have known better and was responsible for ensuring the medications were given correctly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 14 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/20/23 at 2:39 PM, the DON said medications that were extended release were normally not crushed. The DON said if an extended medication was crushed the resident would receive the medication all at once instead of an extended period. The DON said Resident #54's was at risk for her blood pressure or heart rate to drop too low. The DON said the person administering the medication was responsible for ensuring the medications were given correctly. The DON said she was unaware of Resident #54 receiving her medications crushed as she had passed medications before and had not had to crush them. During an interview on 12/20/23 at 3:01 PM, the Administrator said he was unsure if medications that were considered extended release could be crushed or not. The Administrator said the medication aide that was administering the medication was responsible for ensuring medications were given correctly. The Administrator said he was unsure of the side effects for crushing an extended-release tablet but would assume the medication could have had acted more rapidly than wanted. Record review of the facility's Medications Not to be Crushed revised 10/2018, listed Nifedipine extended-release tablet as a medication not to be crushed due to time release formulation. Record review of the facility's policy and procedure Medication Administration Procedure dated 2003, indicated .20. The 10 rights of medication should always be adhered to .1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Right assessment 10. Right evaluation . Note: any deviation from specified and recommended procedures in dispensing or administering medications to the resident requires documented approval by the Quality Assurance Committee and shall be in concurrence with the current statutes and regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 15 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The Dietary staff failed to date all food items. 2) Dietary staff failed to dispose of expired foods items located in the dry storage area. 3) Dietary staff failed to store (2) dented can in a separate area. 4) Dietary staff failed to effectively reseal, label and date frozen food items. 5) The Dietary staff failed test strip on sterilization sink in the three compartment sink 6) The Dietary staff failed to clean the ice machine These failures could place residents at risk for food contamination and foodborne illness. The findings include: During observations on 12/18/23 at 9:58 am, the following observations were made in the kitchen walk in freezer (1 of 4) (1) box of 4 oz Sherbet cups receive date 12/5/23, no open date, no expiration date (1) bag of 6 frozen tortilla not sealed (1) bag of 24 frozen tortilla not sealed. During observations on 12/18/23 at 9:58 am, the following observations were made in the kitchen walk in freezer (2 of 4) (1) 3 pound bag of tator tots receive on 11/13/23, had no open date, no expiration, bag not properly sealed closed. During observations on 12/18/23 at 9:58 am, the following observations were made in the kitchen walk in freezer (3 of 4) (1) 5 pound bag okra not sealed and had a hole in the factory bag. (1) Byron's BBQ sauce chopped beef had a receive date of 10/24/23 and no expiration date. (2) 5 pound Italian Sausage received on 11/21/23, had no expiration date. During an observation and interview on 12/18/23 at 9:58 a.m., The Dietary Manager stated the food in the freezer should have been sealed closed before being put back inside the freezer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 16 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During observations on 12/18/23 at 10:08 a.m., the following observations were made in the kitchen dry storage (1 of 1): Level of Harm - Minimal harm or potential for actual harm (1) 6 pound dented can of Shredded Sauerkraut found with the undented cans Residents Affected - Some (1) 6 pound dented can of Mandarin Oranges found with the undented cans. (1) 5pound box of Complete Cornbread mix received on 12/5/23, no expiration, no open date. (1) 21.5 ounce container of Onion powder seasoning received on 11/21/23, no open date, no expiration date. (1) 16 ounce container of Black Pepper seasoning had no receive date, no open date, no expiration date. (1) container of Mediterranean Style Oregano seasoning had no open date, received on 5/17/22 and expired on 6/14/23. (1) container of Ancho Chile seasoning received on 5/25/23, had no open date, no expiration date. (1) container of Sage seasoning received on 12/22/20, had no open date, no expiration date. During an observation and interview on 12/18/23 at 10:08 a.m., the dietary manager stated the dented can were to be stored separately on the dented can rack. During observation, the ice machine had a black, reddish and brown stain above the ice maker inside the ice machine. Dietary Manager stated the dietary staff were responsible for cleaning the ice machine and the ice machine needed to be cleaned. The Dietary Manager stated the dietary were to clean the ice machine twice a month. During Observation and Interview on 12/18/23 at 10:15a.m., of the 3 compartment sink, the Dietary Manager tested the sanitation solution in the third compartment sink and the sanitation test strip failed. The Dietary Manager stated the test strip failed because hot water was used instead of cold water with the sanitation solution and the sanitation solution only worked with cold water. During an interview on 12/202/23 at 11:08 a.m., [NAME] H stated she had been a cook at the facility for 2 years. [NAME] H stated she was overseen by the Dietary Manager. [NAME] H stated staff were supposed to label and date food with expiration, receive and open dates. [NAME] H said staff were also supposed to ensure that food was sealed tightly in zip lock bags. [NAME] H said when perishable items are open they are only good for 7 days and should have an expiration date on the bag. [NAME] H stated she did not include expiration dates on frozen food items because staff would have used them before seven days of their expiration date. [NAME] H stated the dietary staff was responsible for ensuring dented cans were on the dented can storage rack. [NAME] H stated she did complete in-services on labeling, dating and storing food items last month. [NAME] H stated the Dietician came to the facility two to three times a month for kitchen inspections. [NAME] H stated that the Administrator came twice a month for inspections, and the Dietary Manager inspected the kitchen every day. [NAME] H stated she was responsible for sterilization of the dishes in the 3 compartment sink. [NAME] H stated the first sink was for washing the dishes with soap, the second sink was for plain water and the third sink was for sterilizing the dishes in cold water. [NAME] H stated the sterilization solution used in the third sink was only effective with cold water and not hot water. [NAME] H stated she did not know why she used hot water in the third sink with the sterilization solution. [NAME] H stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 17 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Surveyor made me nervous and I used hot water instead of cold water. [NAME] H stated it was important to ensure the dishes were cleaned and sanitized to prevent residents from getting sick. [NAME] H stated it was important to ensure food was store properly, labeled, dated and expired food items discarded to prevent the dietary staff from serving bad food to the residents. During an interview on 12/20/23 at 12:53 p.m., the Dietician stated she has the Dietician at the facility since 10/2023. The Dietician stated she was not aware of the dented cans stored with the undented cans; frozen food not sealed properly in the freezer; dietary staff using hot water instead of cold water with sterilization solution in the third compartment sink; expired and three year seasoning stored in the pantry. The Dietician stated she was told the best buy date on the seasoning was not harmful to the residents; she only knew the seasoning had a reduced flavor once the best buy date had passed on the seasoning. The Dietician said corporate inspected and educated as necessary. The Dietician stated she did not know how often corporate came for inspections. The Dietician stated she did monthly inspections in the kitchen. The Dietician stated she monitored whether staff are wearing hairnets, gloves, and gives feedback to the dietary manager. The Dietician stated it was important for the dietary staff ensure they were following the facility policy requirements. During an interview on 12/20/23 at 11:15 a.m., the Dietary Manager stated she had been the Dietary Manager for 4 years at the facility. The Dietary Manager stated she was overseen by the administrator and corporate. The Dietary Manager stated it was the responsibility of all staff to ensure that the freezer food items were properly sealed prior to putting freezer food in the freezer. The Dietary Manager stated all staff were responsible for ensuring expired food items were discarded, but she was ultimately responsible. The Dietary Manager stated all staff and she ultimately had responsibility for making sure dented cans were not stacked with undented cans. The Dietary Manager stated she planned to conduct an in-service on labeling and dating, dented cans, and expired foods. The Dietary Manager stated she conducted daily throughs the kitchen and the dietician conducted a walk through inspection once a month, while the administrator conducted inspections twice a month. The Dietary Manager stated [NAME] H was nervous, so she put hot water in the three compartment sink with the solution instead of cold water. The Dietary Manager stated the hot water was ineffective with the sterilization solution. The Dietary Manager stated this was the first time she had seen [NAME] H use hot water rather than cold water. The Dietary Manager stated it was important for staff store dented cans on the dented can rack, label, date and seal frozen foods items, discard expired food to ensure that out of date foods are not served to the residents. During an interview on 12/20/23 at 2:25 p.m., the Administrator stated he tried getting to through the kitchen once a week for inspection. The Administrator stated during his walk throughs in the kitchen he checked to ensure food items were not stored too high for the dietary staff; The Administrator stated he checked the temperature logs in the kitchen; The Administrator stated he was not in the pantry that much for kitchen during his kitchen inspections. The Administrator stated he checked the pantry in the kitchen once a month and inspected the kitchen once a week. The Administrator stated he did not have any recent food complaints from the residents. The Administrator stated the last food complaint was 3 months ago, and it was from a new resident. The Administrator stated the food complaint was regarding salty food. The Administrator stated prior to discharge of the new resident with the salty food complaint that the new resident loved the food. The Administrator stated he got very few food complaints. The Administrator stated he has not seen any in-services on labeling and dating from the dietary staff. The Administrator stated he was not aware of the expired food seasoning, unsealed freezer items, dented cans with undented cans, and hot water being used with the sterilization in third compartment sink. The Administrator stated he did expect the dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 18 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff to ensure frozen items were labeled dated, sealed; dented cans were stored on the dented can rack; cold water was being used with sterilization solution in the three compartment sink and expired food items were being discarded. The Administrator stated it was important for staff store dented cans on the dented can rack, label, date and seal frozen foods items, discard expired food to ensure the residents health and safety and to make sure the dietary staff did not have any bad food or spoiled food. The Administrator stated it was also important to ensure staff were following policies and procedures to ensure quality of life issues as far as flavor and taste of food for the residents. During Record Review of Dietary Services Policy & Procedure Manual 2012 undated revealed, (6) When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it, so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 19 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 halls (Hall 4 and Hall 5) and 4 of 13 staff (CNA L, Floor Tech M, CNA C, LVN F) for infection control practices and transmission-based precautions. Residents Affected - Some 1. The facility failed to follow their policy for testing residents following a COVID-19 outbreak in the facility after Resident #500 residing on Hall 5 tested positive for COVID-19 on 12/14/2023. 2. The facility failed to ensure COVID-19 was not spread to residents on Hall 4. 3. The facility failed to ensure that CNA L and Floor Tech M were tested prior to working their shifts following a COVID-19 outbreak in the facility. 4. The facility did not ensure CNA L performed hand hygiene in between meal trays, during the lunch meal. 5. CNA C failed to perform hand hygiene and change her gloves prior to applying barrier cream to Resident #39's buttock. 6. The facility failed to ensure LVN F sanitized the glucometer after she used it to obtain Resident #219's blood sugar. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: Record review of a face sheet dated 12/20/23 indicated Resident #500 was an [AGE] year-old female admitted to the facility on [DATE] and discharged on 12/17/2023 with diagnoses which included unspecified sequelae of cerebral infarction (disrupted blood flow to the brain), unspecified dementia, unspecified severity (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the Comprehensive MDS assessment Nursing Home discharge date d 12/17/2023 indicated for Resident #500 was incomplete. Record review of the Order Summary Report dated 12/20/2023 indicated Resident #500 was admitted for respite care under the direction of Hospice. Record review of a care plan with initiated dated of 12/12/2023 indicated Resident #500 had a terminal prognosis and/or was receiving hospice services. The care plan did not indicate interventions regarding COVID. During an observation on 12/18/2023 at 9:30 AM, a sign posted on the facility entrance door indicated there was COVID-19 in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 20 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 the initial tour of the facility 12/18/2023 beginning at 10:10 AM, multiple staff members throughout the facility were observed with no face masks. During an observation and interview on 12/18/2023 at 12:10 PM, LVN K said she was the charge nurse for Halls 1 and 2. LVN K said the staff was not required to wear a face mask. She stated there were positive COVID residents in the building. LVN K said the positive COVID residents were on Hall 5. She stated she had a couple of residents on her halls that were being tested on day 1, day 3 and day 5 after being exposed while on smoke breaks with one of the housekeepers that had tested positive. LVN K said those residents that tested were not on any type of isolation precautions. LVN K was observed wearing the mask below her nose. LVN K said the purpose of the wearing the mask appropriately was to prevent the spread of COVID. During an interview on 12/19/2023 at 02:15 PM, the ADON said the residents and staff were only tested for COVID if they showed signs and symptoms of COVID. She said the COVID test were sent out and could take up to a few days to receive results depending on which lab was used. The ADON defined COVID outbreak as 1 resident testing positive. She said she had suggested to the Administrator and the Corporate Compliance Nurse to swab the entire building when the Housekeeping Supervisor tested positive on 12/14/2023, and for all staff to wear the face mask to prevent the spread of COVID. The ADON said she was the infection preventionist and was responsible for infection control for the facility. The ADON said the Administrator and the clinical corporate people made the decision to not test all the staff and residents for COVID and to not require the staff to wear masks. The ADON said the Housekeeping Supervisor took residents to smoke on 12/14/2023. The ADON said the Housekeeping Supervisor tested positive for COVID on 12/14/2023. She said the residents that had been exposed while out smoking with the Housekeeping Supervisor were being tested on day 1, 3 and 5. The ADON said they did not require any type of isolation precautions for the resident's that were exposed while smoking. The ADON said Resident #500 tested positive the following day on 12/15/2023 but had discharged from the facility on 12/17/2023. She said Resident #500 was admitted on [DATE] to the facility for 5 days of respite care due to her daughter/caregiver had tested positive for COVID. The ADON said Resident #500 was not tested for COVID upon admission because it was not the facility's protocol to test for COVID upon admission. The ADON said Resident #500 wandered around the facility prior to testing positive. The ADON said they had no way to determine who Resident #500 had had contact with when she wandered the facility. The ADON said Resident #500 was placed in isolation when she tested positive on 12/15/2023. The ADON said CNA N who had worked on Hall 5 and cared for Resident #500 had also tested positive for COVID on 12/15/2023. The ADON said she was not sure what the CDC recommended at the time, but the facility would follow the recommendations of the CDC. The ADON said it would be beneficial to test the facility to prevent the spread of COVID. The ADON said the facility did not require staff to wear a mask, but wearing a face mask would help decrease the spread of COVID. Attempted telephone call 12/19/2023 at 02:32 PM to Resident #500's daughter. There was no answer to the call. During an interview on 12/19/2023 at 3:00 PM, the Corporate Compliance RN said there were 7 positive cases of COVID in the facility. She said she considered an outbreak to be 1 positive resident. The Corporate Compliance RN said the Housekeeping Supervisor tested positive on the 12/14/2023 after complaining of not feeling well. She said the facility started contact tracing at that time. She said that the Housekeeping Supervisor had taken residents out for a smoke break on 12/14/2023, so testing was completed on those residents with negative results so far. The Corporate Compliance RN said no other staff or residents were tested facility wide. The Corporate Compliance RN said the Housekeeping Supervisor had worked in her office that day. The Corporate Compliance RN said Resident #500 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 21 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 tested positive on 12/15/2023 after symptoms of runny nose and cough. She said they placed Resident #500 on isolation on Hall 5. The Corporate Compliance RN said CNA N tested positive on 12/15/2023. CNA N worked on hall 5 with Resident #500. The Corporate Compliance RN said no other residents or staff were tested facility wide. The Corporate Compliance Nurse said the residents that went out to smoke with the Housekeeping Supervisor should have been recommended to isolate. The Corporate Compliance RN said Resident #500 had wandered throughout the facility prior to testing positive and there was no way to know the proximity of other residents. The Corporate Compliance RN said facility wide testing for staff and residents should have been completed after the first positive COVID results on 12/14/2023 for early recognition and decreasing the spread of COVID. The Corporate Compliance RN said because of not being able to pinpoint who Resident #500, CNA N, and the Housekeeping Supervisor had had contact with, facility testing for staff and residents should have been completed. The Corporate Compliance RN said administration had made the decision not to test and wear mask at that time for source control unless signs and symptoms were present. The Corporate Compliance nurse said upon entering Hall 5, staff was required to wear at least a surgical mask and if entering an isolation room staff was required to wear an N95 mask and appropriate personal protection equipment. During an interview on 12/20/2023 at 10:30 AM, the DON said she defined outbreak as 1 resident testing positive for COVID. The DON said the facility started contact tracing at the time of the first positive COVID test result. She said that the Housekeeping Supervisor had taken residents out for a smoke break, so testing was completed on those residents with negative results so far. The DON said the Housekeeping Supervisor had worked in her office that day with limited interactions with 3 other housekeeping staff members. The DON said another housekeeper and the Activity Director had tested positive for COVID. The DON said Resident #500 tested positive on 12/15/2023 after complaint of runny nose and cough. She said they placed Resident # 500 on isolation on Hall 5. The DON said CNA N who took care of Resident #500 tested positive on 12/15/2023 and testing was completed for all residents of Hall 5. The DON was not able to provide the COVID results of the testing for all the residents of Hall 5. The DON said she thought the ADON/Infection Preventionist had completed the COVID testing for residents on Hall 5 but she had been off work during that time and was not sure why that testing was not completed. The DON said testing should have been completed for all residents on Hall 5 due to resident's having the same staff in and out of the rooms on the hall to help prevent/decrease the spread of COVID. The DON said after receiving the two positive resident's tests yesterday on 12/19/2023 that resided on Hall 4, all residents and staff were being tested. She said as of 12/19/2023 all staff must wear a mask and be tested prior to their shift. The DON said the purpose was to prevent the spread of COVID. Attempted telephone call 12/20/2023 at 11:01 AM to Resident #500's daughter. There was no answer to the call. During an interview on 12/20/2023 at 01:25 PM, CNA L said she had not tested for COVID prior to working her shift on 12/20/2023. She said she was aware that she was supposed to test prior to working but could not provide a reason why she had not tested. CNA L said the purpose of COVID testing prior to working was to prevent the spread of COVID by detecting infection before the residents come into contact with COVID. During an interview on 12/20/2023 at 02:48 PM, the Floor Tech M said he had not tested for COVID prior to working the day shift on 12/20/2023. He stated he was aware that he was supposed to be tested prior to working but had not tested. The Floor Tech M said the purpose of COVID testing prior to working was to ensure he did not spread the sickness to other staff and residents while working. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 22 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 12/20/2023 at 03:50 PM, the Administrator said the facility's protocol was to not test for COVID upon admission. The Administrator defined COVID outbreak as 1 resident testing positive. The Administrator said that testing was only done with complaint of signs and symptoms of COVID. He said the staff was educated to monitor for signs and symptoms of COVID. The Administrator said he did not feel that it was recommended by the CDC to test the facility and staff until residents started testing positive for COVID on Hall 4. The Administrator said he felt that the contact tracing was the appropriate intervention at the time of the COVID outbreak. He said that training and education of the staff could resolve the spread of infectious diseases. The Administrator said he had been made aware of the CNA L and the Floor Tech M that had worked their shifts without testing. The Administrator said both staff had now been tested. The Administrator said the decision regarding COVID control was made by the ADON, DON, Corporate Compliance Nurse, and himself. Record review of the undated COVID Positive Timeline provided by the Administrator on 12/20/2023 at 03:50 PM indicated the following: 12/14/2023 Resident #500 tested positive for COVID Self-report initiated. Contact Tracing Initiated Staff notified that if they had known direct exposure to this resident to mask and start monitoring symptoms and begin testing themselves 12/15/2023 as Day 1 then Day 3 and Day 5. Resident roommate started testing 12/15/23 as Day 1 then Day 3 and 5. Residents identified to have known direct exposure were also started on monitoring symptoms and testing 12/15/23 as Day 1 then Day 3 and Day 5. (Resident: #8 and #65 - Residents have been negative.) 12/14/23 Housekeeping Supervisor tested positive for COVID Housekeeping Supervisor reported that she began feeling symptoms the afternoon of 12/13/23 so she started wearing a mask and took COVID test. Test was negative. She came in the morning of 12/14/23 and took another COVID test at approximately 07:00. Test was negative, but she was feeling so bad, she took another one to be sure, and there was a very faint line. She brought it to this Administrator. She was instructed to go home for the day and come back in the afternoon to test again. She returned the afternoon of 12/14/23 between 1500 and 1600 and tested again. She was clearly positive. She was sent home. This was after we had gotten the report of the resident positive. She was interviewed about her work activities on 12/13/23. She stated she had not been around the building that day and was working in her office throughout the day. She had not had any close interaction with residents but did have 3 staff members in her office with her. Those staff members (Housekeeper O, Housekeeper P, and the Activity Director) were notified and told to begin testing 12/15/23 as Day 1 and then Day 3 and 5. 12/15/2023 The Activity Director called in the morning of 12/15/23 and said that she was sick and was going to the ER. She reported back that she was not COVID positive but did have the flu and would be out at least five days. CNA N tested positive for COVID. She was one of the staff members who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 23 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 had cared for resident #500. She had been wearing a mask on her previous shifts. Her last shift was 12/13/23, so she had not worked on 12/14 and 12/15. Inservices for all staff was initiated on Isolation Precautions, PPE, Seal check and Hand Hygiene 12/17/23 Housekeeper tested before her shift because she was feeling bad. Test was negative, but she left for the day and went to urgent care. She reported that she tested positive at urgent care, but that the results were not on her paperwork and the clinic told her she could go back to work in 5 days. She was instructed to test on day 5 12/20 and then day 7 and with two negatives she could return to work on Day 8 - 12/23. She reported to have symptoms start on 12/15. Three residents tested positive for COVID, all on Hall 5 where the original COVID positive resident was staying. Resident #59, Resident #41, and Resident #57. Covid positive residents were isolated and put on precautions. Covid positive residents' roommates were quarantined warm and placed on precautions. Residents #9, #48, #55 for 7 days and testing day 1.3.5 and 7. All staff with direct exposure to positive residents were instructed to mask and begin monitoring symptoms and testing 12/18/23 as Day 1, then days 3 and 5. Staff members working on and entering Hall 5 were instructed to wear source control when on Hall 5. 12/18/23 Physical Therapist Assistant R tested positive on the morning of 12/18/23 and left the building. Her last worked was 12/15/23 and she had not worked with any residents the morning she tested positive. Resident #64 tested positive. He was moved down to an isolation room on precautions. His roommate remained in his room and was placed on warm quarantine for 7 days with testing 1, 3, 5, and 7. At this time all resident positives were contained on Hall 5. 12/19/23 Residents #20 and #5 tested positive for COVID. Both residents were on Hall 4. Resident #20 was kept in his room in isolation and placed on transmission-based precautions. His roommate, #35 was moved to a room on quarantine precautions for 7 days testing on days 1, 3, 5, and 7. Resident #5 was moved to room [ROOM NUMBER]A with another COVID positive resident on precautions. Her roommate, #52 remained in her room and was placed on quarantine precautions for 7 days testing on days 1, 3, 5, and 7. All residents in the facility were tested on [DATE] as day 1 and will be tested every three days until facility is out of outbreak. All staff were instructed to wear source control at all times while in public/resident areas in the facility. All staff were instructed to begin COVID testing starting with staff present on this day and to test every 3 days until facility is out of outbreak. All staff who were not working on this day were notified by managers to test prior to their next shift and then test every 3 days. 2. During an observation on 12/20/2023 at 12:14 PM, CNA L was passing out meal trays on Hall 1. CNA L took a meal tray to a resident in room [ROOM NUMBER], came back to the tray cart, took another meal tray to room [ROOM NUMBER], and did not perform hand hygiene. During an interview on 12/20/2023 at 1:25 PM, CNA L stated staff should perform hand hygiene between different resident's meal trays. CNA L stated she normally performed hand hygiene while passing out meal trays, but she was nervous. CNA L stated performing hand hygiene was important, so staff did not pass germs from room to room. During an interview on 12/20/2023 PM, 02:35 PM, the Corporate Compliance Nurse said staff should have performed hand hygiene while passing meal trays. The Corporate Compliance nurse stated this was monitored by random observations and education. She said performing hand hygiene was important because of infection control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 24 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 3. Record review of a face sheet dated 12/19/2023 indicated Resident #39 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included cerebral infarction (necrotic tissue in the brain), hemiplegia affecting right side (muscle weakness) and hypertension (high blood pressure). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #39 had a BIMS score of 9 indicating moderately impaired cognition. The MDS indicated Resident #39 required assistance of two or more helpers to complete toileting hygiene due to Resident #39 contributing no effort to complete the activity. Record review of the care plan revised on 04/20/2023 indicated Resident #39 required one person assistance with personal hygiene. During an observation and interview on 12/18/2023 at 11:49 AM, CNA C cleaned Resident #39's buttock after a bowel movement and did not perform hand hygiene or change gloves prior to applying barrier cream to Resident #39's buttock. CNA C stated she did not perform hand hygiene or change her gloves prior to applying barrier cream because she got nervous. CNA C stated the importance of completing incontinent care correctly was to prevent the spread of bacteria or cause an infection. CNA C said she was responsible for providing proper incontinent care and had been checked off that she understood how to do it correctly. During an interview on 12/20/23 at 1:49 PM, the DON stated CNAs were required to complete checkoffs indicating they knew how to do incontinent care correctly and spot checking on the CNAs was performed to make sure they were still proficient. The DON stated she expected CNAs to perform incontinent care correctly and all the nurses were responsible for making sure the CNAs were completing it correctly. The DON stated if incontinent care was not done correctly, it could cause skin breakdown or infection. During an interview on 12/20/23 at 3:12 PM, the Administrator stated he expected incontinent care to be done correctly. The Administrator stated the CNA completing incontinent care would be responsible for making sure it was done correctly since they had been checked off. The Administrator stated if incontinent care was not done correctly, it could lead to an infection or cause an UTI. 4. Record review of the Resident #219's face sheet dated 12/20/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a group of diseases that result in too much sugar in the blood, essential hypertension (high blood pressure), and congestive heart failure (a chronic condition in which the heart does not pump as well as it should). Record review of Resident #219's electronic medical record on 12/20/23, did not reveal a completed MDS assessment. Record review of Resident #219's comprehensive care plan dated 12/18/23, indicated he had diabetes with interventions to administer diabetic medications as ordered. Record review of Resident #219's order summary report dated 12/20/23, indicated he had an order for insulin glargine (long-acting insulin) subcutaneous (under the skin) solution pen injector 100 unit/ml inject 14 units subcutaneously one time a day with an order start date of 12/20/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 25 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 observation and interview on 12/19/23 at 11:43 AM, LVN F entered Resident #219's room and obtained his blood sugar and then exited the room. LVN F placed the used glucometer inside the nurse's cart without sanitizing it. When asked why she did not sanitize the glucometer prior to placing it inside the cart, she said obtaining the blood sugar was something they did quickly, and it slipped her mind. LVN F said she was responsible for ensuring the glucometer was cleaned after each use and by not doing so was an infection control issue. During an interview on 12/20/23 at 2:17 PM, the ADON said she expected the glucometers to be cleaned after each use and before it was placed in the cart. The ADON said by not cleaning the glucometer placed residents at risk for blood borne pathogens and a potential for infection. The ADON said the person utilizing the glucometer was responsible for cleaning the glucometer after they used it. During an interview on 12/20/23 at 2:39 PM, the DON said she expected the glucometers to be cleaned with a sanitizing wipe after each use. The DON said the nurse who used it was responsible for cleaning the glucometer. The DON said by not cleaning the glucometer after each used placed the residents at risk for infection or incorrect blood sugar readings. During an interview on 12/20/23 at 3:01 PM, the Administrator said he expected the glucometers to be cleaned after each use. The Administrator said the charge nurse or the nurse using it was responsible for cleaning the glucometer and by not doing so was an infection control issue. Record review of the facility's policy titled, Infection Control Policy and Procedure Manual, updated on May 2023, indicated, . Source Control is recommended for individuals in healthcare setting who: Have suspected or confirmed SARS-CoV-2 infection or other respiratory infections (e.g., those with runny nose, cough, sneeze); or Had close contact (patient and visitors) or a higher - risk exposure with someone with SARS-CoV-2 infection, for 10 days after their exposure. Perform SARS. CoV-2 Viral Testing Table 1 . Symptomatic individual identified - staff, regardless of vaccination status, with signs or symptoms must be tested. Residents, regardless of vaccination status, with signs or symptoms must be tested. Newly identified COVID 19 positive staff or resident in a facility that can identify close contacts - Test all staff, regardless of vaccination status, facility wide or at a group level if staff are assigned to a specific location where the new case occurred of the facility. Test all residents, regardless of vaccination status, facility wide or at a group level if staff are assigned to a specific location where the new case occurred of the facility. Newly identified COVID 19 positive staff or resident in a facility that is unable to identify close contacts - Test all staff, regardless of vaccination status, facility wide or at a group level if staff are assigned to a specific location where the new case occurred of the facility. Test all residents, regardless of vaccination status, facility wide or at a group level if staff are assigned to a specific location where the new case occurred of the facility . Record review of Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated on May 8, 2023, accessed on 12/28/2023 on the CDC website indicated, The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency . Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing . Source control is recommended for individuals in healthcare settings who: Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure . Asymptomatic patients with close contact with someone with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 26 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 . Record review of Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when SARS-CoV-2 and Influenza Viruses are Co-circulating accessed on 12/28/2023 on the CDC website indicated, . New SARS-CoV-2 infection identified in HCP or nursing home-onset infection in a resident should prompt additional testing of other residents and staff in the facility . Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, updated May 2023, indicated, .1. Hand Hygiene continues to be the primary means of preventing transmission of infection. The following is a list of some situations that require hand hygiene .before or after handling food .before or after assisting resident with meals . Record review of the facility's policy titled, Personal Care, dated 04/25/2022, indicated, the procedure aims to maintain the residents dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . Record review of the facility's policy and procedure Glucometer revised on February 13, 2007, indicated . 4. Maintenance 1. Clean and inspect meter exterior with each use. 2. Meter will be cleaned with a germicidal and allowed to air dry between patient testing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 27 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 3 of 21 employees (Dietician, ST, and OT) reviewed for required annual trainings. Residents Affected - Some The facility failed to ensure the Dietician received annual HIV training. The facility failed to ensure the Dietician, ST, and OT received annual Restraint training. These failures could place residents at risk for the inappropriate use of restraints and exposure to HIV. Findings included: Record review of the employee files revealed there was no annual HIV training completed for the following staff: *Dietician (hire date 9/20/19) Record review of the employee files revealed there was no annual restraint training completed for the following staff: *Dietician (hire date 09/20/19), *ST (hire date 02/02/18), *OT (hire date 08/10/22), During an interview on 12/20/23 at 3:03 PM, the HR coordinator stated she was responsible for making sure the annual trainings were completed. The HR coordinator stated the facility did paper testing until 2021, then corporate informed her the paper test was no longer necessary. The HR coordinator stated corporate failed to load the training into the computer from the skilled nursing clinic. The HR coordinator stated the importance of completing annual training was to make sure the employees knew the policies and procedures on restraints and the HIV process. The HR coordinator stated if the trainings were not completed, then staff might not know how to handle a resident that was restrained or how to care for a resident with HIV. The HR coordinator stated she was not aware that the facility needed to keep track of training on contracted employees and there was no process in place to double check her. The HR coordinator stated she checked the reports in Relias daily but did not look at each individual training that was required. During an interview on 12/20/23 at 3:12 PM, the Administrator stated he expected the annual trainings to be completed. The Administrator stated corporate was responsible for making sure the facility received the information on staff that required annual training, and the HR coordinator was responsible for making sure staff completed the trainings. The HR coordinator was responsible for running daily reports in Relias to make sure trainings were complete on all staff. The Administrator stated there was no process in place to double check the HR coordinator and the failure must have occurred when the facility changed from the skilled nursing clinic to Relias. The Administrator stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 28 of 29 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 675177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Tree Lodge Nursing Center 2711 Pine Tree Rd Longview, TX 75604 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 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete importance of annual HIV training was so staff had accurate information that was up to date. The Administrator stated the importance of restraint training was for resident safety and making sure staff knew the facility was a zero-restraint facility. The policy on required trainings was requested on 12/20/23 at 3:30 PM and the Administrator stated, we do not have an actual training policy on HIV and restraint training and follow the requirements of training hours per the state guidelines. Event ID: Facility ID: 675177 If continuation sheet Page 29 of 29