Health inspection·January 23, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few about Resident #2's concerns. LVN B stated she was not notified by the CNA that the resident needed assistance. She stated she had been down the hall several times that morning and Resident #2's call light was not on. LVN B stated the phone had not rung during the time frame of the resident's concern. The Administrator interviewed CNA A. CNA A acknowledged that she went into Resident #2's room, and she told him she was starting her last rounds and would go and get someone to assist her with helping him. She said she had turned off his call light, and left the door opened to remind her to go back. CNA A said she forgot to go back because she got busy with other residents. She said Resident #2 did not turn his call light back on. CNA A said it was an honest mistake and she was sorry. The LVN B was attending Resident #2 at 6:00 a.m. when the Administration informed her of Resident #2's concern. At that time, she asked the resident if he needed a pain pill, and he shook his head yes . The pain pill was administered by LVN B. The Grievance forms corrective action taken to prevent recurrence was CNA A was in serviced by the Administrator by phone that a resident call light should never be turned off until the resident need is met and that the light is a reminder to go back and take care of the resident. A written coaching was also completed for this CNA. And all staff in service was initiated by the Administrator the morning of this concern. An in service was initiated by the Administrator on keeping hallways quite during hours of sleep. Resident #2 had the Administrator's phone number and was informed that he could call at any hour if something like this happened again. During an interview on 1/22/24 at 11:20 a.m. Resident #2 said he pulled his call light about 3:30 a.m. on 1/21/24 and CNA A came in an asked him what he wanted. He said he told her he wanted some water to drink and the nurse to come and check his colostomy. He said the aide turned off the call light and did not return. He said around 5:45 a.m. he called the nurses station and LVN B finally came to see what he wanted. She had to fix his colostomy and because he had laid in the same position for so long, he was in pain and needed a pain pill. During an interview on 1/22/24 at 12:25 p.m. the Administrator said he received the complaint on Resident #2 about staff coming in and turning off his call light and not coming back. He said he had received a text from the resident about 5:30 a.m. on the morning of 1/21/24 that said he had pulled the call light at 3:30 a.m. and the aide came in and turned it off. He said he had counseled the aide and completed an in-service regarding the call light being answered. Record review of an in serviced dated 1/21/24 indicated when answering a resident's call light never, never, never turn off the residents call light without addressing the resident need. Do not turn off the call light and tell the resident you will come back in a minute. Leave the call light on until the residents need had been completely addressed. It was signed by CNAs, nurses, and medication aides. Another in-service about being quiet in the halls during hours of sleep. Record review revealed a Coaching Form dated 1/21/24 regarding CNA A. The form indicated the aide had answered Resident #2's call button, turned it off and not provided care. The aide said she had forgotten to go back. She was counseled by the Administrator to Never turn off a residents call light without providing care. The form was signed by CNA and the Administrator. CNA A and the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 2 of 10 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 01/23/2024 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident had the right to privacy for 1 of 3 residents reviewed for privacy. (Resident #1) Residents Affected - Few Resident #1 was not fully dressed when the Maintenance Director entered her room without knocking. This noncompliance was identified as PNC. The noncompliance began on 1/15/24 and ended on 1/15/24. The facility corrected the noncompliance before the survey began. This negative finding could cause the resident embarrassment and discomfort. Findings included: Record review of Resident #1's face sheet dated 1/22/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia, depression, difficulty walking, lack of coordination, reduced mobility, and need for personal care assistance. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had severely impaired cognitive impairment. She required extensive assist of two people with bed mobility, and transfers. Record review of Resident #1's Care Plan dated 9/19/23 indicated a Focused area of at risk for ADL self-care performance deficit. The goal was the resident would maintain or improve current level of function with bed mobility, transfers, eating, dressing toilet use and personal hygiene. Some of the interventions were Resident #1 required staff assistance of one person form bathing on TTHS on the 6a to 6p shift. The resident required the assistance of one person for bed mobility, dressing and eating. The resident used a wheelchair for ambulation. She required the assistance of two staff for the use of a bed pan. A Care Plan update on 1/19/24 indicated the resident required total assist with all transfers with a Hoyer lift. Record review of a Resident Grievance dated 1/15/24 indicated Resident #1's family member reported the Maintenance Director entered Resident #1's room when she was being dressed by CNAs without knocking. The Grievance form's summary of the pertinent findings and conclusions induced the Maintenance Director was called by CNA C/staffing coordinator to come to the room and fix Resident #1's bed. When the Maintenance Director arrived, the door was closed, and he entered without knocking. Resident #1's family reported when he entered the resident did not have her shirt on and was being dressed by two aides. The Grievance forms corrective action taken to prevent recurrence was the Maintenance Director was immediately in serviced on knocking on resident doors before always entering. When the door is closed to wait to hear from the resident or care team that he can enter. Observation of a video dated 1/15/24 at 9:58 a.m. revealed CNA C/staffing coordinator and CNA D getting Resident #1 dressed sitting on the side of the bed. They had just her up and was putting on her blouse. She did not have on anything else; her breast was exposed. The two staff had one arm in the blouse but stopped as the Maintenance Director came into the room. There was no knock heard. He asked what they needed, and they told him the bed would not go up. He walked around the side of the bed and began fixing something. The two aides continued to dress the resident. He said try it now, they said it was fine and he left. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 3 of 10 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 01/23/2024 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/22/24 at 12:25 p.m. the Administrator said the Maintenance Director and the aides were in serviced on knocking and making sure the residents are fully clothed before entering the room. He had conducted an in service on the incident. During an interview on 1/22/24 at 12:53 p.m. CNA C/ Staffing coordinator, said she was in the room assisting CNA D with getting Resident #1 up. The bed would not go up or down, so she had stepped to the nurse's station. She said asked the nurse to call the Maintenance Director to fix the bed. She said she remembered after the fact that he did not knock. She said they were dressing Resident #1 and she did not remember the exact state of her undress when the Maintenance Director came in the room. He fixed the bed, and they proceed to get the Resident up. She said she had been counseled about the incident. During an interview on 1/23/24 at 8:39 a.m. the Maintenance Director said he was called to Resident #1's room. He said he was moving fast and had fixing the problem on his mind. He said he remember that day well, he had been counseled about the incident. He said he did not knock because someone had requested his presence to fix something. He said he could not say what state of dress the Resident #1 was in; he did not pay her any attention. The Maintenance Director said he would always knock from now on. Record Review of an in-service training dated 1/15/24 titled entering a room without knocking was addressed to the Maintenance Director. The in service indicated all staff should knock on doors before entering a resident room. The staff should wait for permission to enter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 4 of 10 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 01/23/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received the necessary care and services to maintain the highest practicable wellbeing consistent with the resident comprehensive assessment and care plan for 2 of 3 residents reviewed for quality of life in that: (Resident #1 and Resident #2.) Residents Affected - Few Resident #1 did not receive showers as scheduled and she was not transferred according to her care plan. Resident #2 did not receive care and services as requested when the aide turned off his call light and did not return for 3 hours. His care plan indicated he was to be turned and repositioned every two hours and receive colostomy care as needed. This negative finding could cause resident to have a decline in their physical, and psychosocial wellbeing. Findings included: Resident #1 Record review of Resident #1's face sheet dated 1/22/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia, depression, difficulty walking, lack of coordination, reduced mobility, and the need for personal care assistance. Record review of Resident #1's quarterly MDS dated [DATE] indicated she was severely cognitively impairment. She required the extensive assist of two people with bed mobility, and transfers. Record review of Resident #1's Care Plan dated 9/19/23 indicated a Focused area of at risk for ADL self-care performance deficit. The goal was the resident would maintain or improve current level of function with bed mobility, transfers, eating, dressing toilet use, and personal hygiene. Some of the interventions were Resident #1 required one person staff assistance with bathing on TTHS on the 6a to 6p shift. The resident required the assistance of one person for bed mobility, dressing and eating. The resident used a wheelchair for ambulation. She required the assistance of two staff for the use of a bed pan. A Care Plan was update on 1/19/24 and indicated the resident required total assist with all transfers with a Hoyer lift transfer. Record review of a Quality Assurance Action Plan dated 10/27/23 indicated a plan for the showers for residents to ensure that showers are getting done. We are developing a new practice and monitor. During champion Rounds ask residents if they are getting their showers. Record review of Resident #1's computerized ADL sheet for January 2024 indicated she had received a shower on Thursday 1/4/24, Thursday 1/11/24, Tuesday 1/16/24 and on Saturday 1/20/24. Review of the schedule indicated she should have received 9 showers through January 20, 2024, and she only received 4. Record review of handwritten shower sheets indicated Resident #1 received a shower on 12/12/34.2/28/23, and 12/30/23. There were handwritten shower sheets dated 1/3/24 and 1/11/24. The sheets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 5 of 10 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 01/23/2024 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 0677 indicated showers were given to several residents to include Resident #1 and did no have any signatures. Level of Harm - Minimal harm or potential for actual harm Record review of a Resident Grievance form dated 1/3/24 indicated Resident #1's family member called the Administrator and reported concerns Resident#1 had not received a shower for 5 or 6 days. The family member said there was some confusion over whether the resident was to be showered during the day shift or the night shift. The family member wanted Resident #1 showered during the day. The Grievance forms pertinent finding and conclusions were Resident #1 was moved from the A bed to the B bed. There were problems with the way the shower schedule was set up in the facility Plan of Care computer system. The resident had not been receiving showers as scheduled since the change in the system. It had not reflected in the computer system because of the scheduling problem in the system. The corrective action taken to prevent recurrence was the care team was notified Resident #1's shower schedule was TTHS on the day shift. The schedules were corrected and were populating in the computer system correctly at the current time. Residents Affected - Few During an interview on 1/22/24 at 4: 15 p.m. the Corporate RN said they had a computer error regarding the showers and the way they were scheduled in the computer. Resident #1's was changed and placed in the system but the way it was changed it did not populate to show she was not getting her showers. They have a secondary method to check which was the shower sheets. The Corporate nurse said she could only find three shower sheets for Resident #1 for December and 2 for January. She said only the PRN bath schedule populated for December and it showed one shower for December 29, 2023. She said they knew she received more than 3 showers for December, but they could not prove that she did. The DON went into the computer to fix the system and apparently there was a glitch in the system. She said they did the computer updates as a form of corrective action and Resident #1 was the only resident affected. They had found the problem and corrected it after it was brought to the attention by the family. Record review of a Resident Grievance form dated 1/5/24 indicated a concern from Resident #1's family member that a staff member had transferred Resident #1 unassisted, and Resident #1 was a two person assist. The family member indicated Resident #1 had a prior neck injury and the staff had handled her neck incorrectly. The Grievance forms corrective action taken to prevent recurrence was CNA E was counseled about using proper transfer techniques and she received a one on one in service from the nurse. Observation of a video dated 1/5/24 at 6:47 a.m. revealed CNA E sitting Resident #1 on the side of the bed. Resident #1 leaned back on the bed and laid her head down on the bed. CNA E put a gait belt around the resident and tighten it. She then put one hand behind Resident #1's head and lifted her by the neck. The resident hollered out. The aide told the resident she was going to transfer her. She used the gait belt but during the transfer the belt rose high on her back and was not around her waist. CNA E placed Resident #1 in the wheelchair, and it did not appear that Resident #1 assisted with the transfer. During an interview on 1/22/24 at 12:25 p.m. the Administrator said that Resident #1 was now a lift transfer. He was aware of the family concerns of only one person transferring Resident #1. He said there was a mix up with the shower schedules. They had a system error. He received a complaint on 1/3/24 about Resident #1 not receiving showers as indicated. He said he did not believe she did not receive showers during that time, but the documentation showed differently, and they could not prove otherwise. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 6 of 10 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 01/23/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 1/22/24 at 3:35 p.m. CNA E said she did transfer Resident #1 by herself. She said forgot Resident #1 was a two-person transfer. She said did not normally work that hall. She had been counseled on making sure of the resident transfer status and getting the required number of people before transferring residents. Residents Affected - Few Resident #2 Record review of Resident #2's face sheet dated 1/17/24 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were anxiety disorder, colostomy status, quadriplegia (paralysis of all four limbs) contracture of the right hand, seizures, stroke, stage 4 pressure ulcer of the left hip, and need for assistance with personal care. Record review of Resident #2's quarterly MDS dated [DATE] indicated he had no cognitive impairment. His upper and lower extremities were impaired on both sides. Record review of Resident #2's care plan indicated a Focus was quadriplegia (paralysis in 4 limbs). One of the interventions was Resident #2 would receive assistant with ADLs and locomotion as required. Resident #2 had a Focus are of he had a suprapubic catheter. One of the interventions was to ensure the tubing was anchored to the resident's leg or lines so that the tubing was not pulling on the urethra. Resident #2 had a Focused area of having a colostomy. One of the interventions was to preform ostomy care as needed. Resident #2 had a Focused area of pain medication therapy. One of the interventions were administer pain medication as ordered. Resident #2 had a Focused area of a history of making false statements and negative attention seeking behavior. Some of the interventions were to always have two care givers provide care, and counseling services. Resident #2 had a Focused area of Stage 4 pressure ulcer to the left hip. One of the interventions were the resident needed assistance to turn and reposition at least every two hours. Review of a Resident Grievance form dated 1/21/24 indicated Resident #2 reported to the Administrator that at 3:30 a.m. he pushed the call button. He said he needed to be turned, ice water, and his colostomy bag emptied. He said an aide came in after 30 minutes and turned the light off. She said she would get help and did not return. Resident #2 said he pulled the call button again around 4:50 a.m. and called the nurses station on the phone numerous times with no answer. Resident #2 stated the door was left opened and it was noisy in the hall, and he needed a pain pill. The Grievance report contained a summary of the pertinent findings and conclusions. The Administrator interviewed LVN B about Resident #2's concerns. LVN B stated she was not notified by the CNA that the resident needed assistance. She stated she had been down the hall several times that morning and Resident #2's call light was not on. LVN B stated the phone had not rung during the time frame of the resident's concern. The Administrator interviewed CNA A. CNA A acknowledged that she went into Resident #2's room, and she told him she was starting her last rounds and would go and get someone to assist her with helping him. She said she had turned off his call light, and left the door opened to remind her to go back. CNA A said she forgot to go back because she got busy with other residents. She said Resident #2 did not turn his call light back on. CNA A said it was an honest mistake and she was sorry. The LVN B was attending Resident #2 at 6:00 a.m. when the Administration informed her of Resident #2's concern. At that time, she asked the resident if he needed a pain pill, and he shook his head yes . The pain pill was administered by LVN B. The Grievance forms corrective action taken to prevent recurrence was CNA A was in serviced by the Administrator by phone that a resident call light should never be turned off until the resident need is met and that the light is a reminder to go back and take care of the resident. A written coaching was also completed for this CNA. And all staff in service was initiated by the Administrator the morning of this concern. An in service was initiated by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 7 of 10 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 01/23/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator on keeping hallways quite during hours of sleep. Resident #2 had the Administrator's phone number and was informed that he could call at any hour if something like this happened again. During an interview on 1/22/24 at 11:20 a.m. Resident #2 said he pulled his call light about 3:30 a.m. on 1/21/24 and CNA A came in an asked him what he wanted. He said he told her he wanted some water to drink and the nurse to come and check his colostomy. He said the aide turned off the call light and did not return. He said around 5:45 a.m. he called the nurses station and LVN B finally came to see what he wanted. She had to fix his colostomy and because he had laid in the same position for so long, he was in pain and needed a pain pill. During an interview on 1/22/24 at 12:25 p.m. the Administrator said he received the complaint on Resident #2 about staff coming in and turning off his call light and not coming back. He said he had received a text from the resident about 5:30 a.m. on the morning of 1/21/24 that said he had pulled the call light at 3:30 a.m. and the aide came in and turned it off. He said he had counseled the aide and completed an in-service regarding the call light being answered. Record review of an in serviced dated 1/21/24 indicated when answering a resident's call light never, never, never turn off the residents call light without addressing the resident need. Do not turn off the call light and tell the resident you will come back in a minute. Leave the call light on until the residents need had been completely addressed. It was signed by CNAs, nurses, and medication aides. Another in-service about being quiet in the halls during hours of sleep. Record review revealed a Coaching Form dated 1/21/24 regarding CNA A. The form indicated the aide had answered Resident #2's call button, turned it off and not provided care. The aide said she had forgotten to go back. She was counseled by the Administrator to Never turn off a residents call light without providing care. The form was signed by CNA and the Administrator. CNA A and the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 8 of 10 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 01/23/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a therapeutic diet as ordered by the physician for 1 of 3 residents reviewed for diets (Resident #1), in that: Resident #1 had a physician order for magic cups three times a day that were not provided for two meals. This negative finding could contribute to Resident weight loss. Findings included: Record review of Resident #1's face sheet dated 1/22/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were unspecified protein calorie malnutrition, dementia, anxiety, and difficulty swallowing. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had severely impaired cognitive impairment. She required extensive assist of two people with bed mobility, and transfers. She required one-person physical assist with eating. Record review of Resident #1's Care Plan dated 9/19/23 indicated a Focused area of at risk for malnutrition. The goal was for her to maintain a stable weight and nutritional parameters. Some of the interventions were to give nutritional supplements as ordered and offer the diet as ordered by the physician. She had an additional Care Plan Focused area identified 1/19/24 of significant unplanned/unexpected weight loss due to poor food intake and recent hospitalization. The goal was the resident to consume 50 percent of at least two of her three meals a day. Some of the intervention to give the supplements as ordered. The supplements are magic cup three times daily. Place a red glass on the resident's tray to identify the resident to staff and needing assistance encouragement, and substitutes. Hands on assistance to be provided during meals. Record review of an individualized physician's order dated 1/19/24 indicated supplement, three times a day for weight loss poor intakes give with meals, may give supper pudding if magic cup is not available. Record review of Resident #1's computerized physician orders indicated she had orders for regular diet purred texture, nectar consistency dated 1/20/24, and an order for magic cup three times daily. During an observation on 1/22/24 at 4:40p.m. Resident #1 had a red glass on her puree tray. The meal was sub- sandwich, soup, and ice cream. Resident #1 had something that looked like gravy on potatoes, and one puree green substance and other pureed unidentified item and sherbet. She received her plate with pureed diet and two glasses of nectar thickened liquids, and sherbet. There was no magic cup. During an interview on 1/22/24 at 4:50 p.m. kitchen staff said they were out of magic cups and that is why Resident #1 did not get one. She got the Sherbet instead. She said she did not get the supper pudding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 9 of 10 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 01/23/2024 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 0808 Observation of the meal on 1/22/24 showed all residents got sherbet for dessert. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/22//24 at 6:30 a.m. the Dietary Manager said they had been out of magic cups for a couple of days. They had just got a truck in today. They were substituting the magic cup with supper pudding. Residents Affected - Few Record review of a meal ticket dated 1/23/24 indicated Resident #1 had a puree tray with 4 oz of nectar cranberry juice, hot cereal, bread southern biscuit, margarine, jelly, and nectar whole milk. There was no notation of a magic cup. Observation on 1/23/24 at 7:25 a.m. Resident #1 got her tray which contained, cream of wheat, looked like puree sausage, and eggs, margarine, jelly, nectar thick cranberry juice and nectar thick milk. There was no magic cup on her tray. During an interview on 1/23/24 at 850 a.m. the Dietary Manager said the menu for yesterday dinner meal was Tucana Soup, Sub- sandwich, and sherbet. The Dietary Manager said Resident #1 was supposed to have the super pudding instead of the magic cup. She said it would have been in a separate container on the side. She said she had the physician's order for Resident #1 to have magic cups she did not know why it was not on her meal slip or why she did not receive it this morning. Record review of a Supplements policy from the Dietary Services Policy and Procedure Manual 2012 indicated Physician order supplements will be prepared and delivered by the Dietary Department according to facility policies. All supplement orders are to be documented on the supplement list by the Dietary Service Manager or designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 10 of 10