Health inspection·June 19, 2024

F 0677 *05/17/24 Bed Bath by CNA A Level of Harm - Minimal harm or potential for actual harm *05/22/24 Bed Bath by CNA A *05/25/24 Bed Bath by CNA A Residents Affected - Some *05/27/24 Bed Bath by CNA A *05/29/24 Refused/Other *06/05/24 Bed Bath by CNA A Record review of the facility's resident roster dated 06/12/24 indicated Resident #1 was out of the facility. 2. Record review of Resident #2's face sheet dated on 06/12/24 indicated Resident #2 was a [AGE] year-old, male and was admitted on [DATE] and 05/15/24 with diagnoses including cerebral infarction (stroke), muscle wasting and atrophy (shortening), and hemiplegia (paralysis of one side of the body) and hemiparesis (is weakness or the inability to move on one side of the body) following cerebral infarction affecting left non-dominant side. Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS indicated Resident #2 had a BIMS score of 11 which indicated moderate cognitive impairment. The MDS indicated Resident #2 did not reject care. The MDS indicated Resident #2 required supervision or touching assistance for shower/bathe self. Record review of Resident #2's care plan dated 05/31/24 indicated Resident #2 had an ADL self-care performance deficit. Intervention included bathing required one staff assistance. Record review of Resident #2 ADL bathing report dated May 2024 indicated no documentation for 3 (05/11, 05/16, 05/28) out of 13 scheduled bath/showers. The ADL bathing report indicated Resident #2's shower days were Tuesdays, Thursdays, and Saturdays on night shift. Record review of Resident #2's ADL bathing report dated 06/2024 indicated no documentation for 3 (06/04, 06/08, 06/11) out of 5 scheduled bath/showers. The ADL bathing report indicated Resident #2 shower days were Tuesdays, Thursdays, and Saturdays on night shift but switched to day shift on 06/08/24. Record review of Resident #2's shower list sheets dated May-June 2024 indicated: *05/09/24 Shower by CNA B *06/04/24 Shower by CNA A During an observation and interview on 06/12/24 at 5:15 p.m., Resident #2 said he did not get his scheduled showers. He said he was supposed to get a shower three times a week but sometimes he only got it twice. He said he used to be on the night shift schedule but asked to be moved to day shift. He said he moved to day shift hoping he would get his scheduled showers. He said he was supposed to get his showers in the morning, but the aides did not know what morning was because they tried to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 2 of 5 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 06/19/2024 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 - Some give him showers in the afternoon. Resident #2 had a baseball cap on his head so unable to assess his hair. 3. Record Review of Resident #3's face sheet dated 06/12/24 indicated Resident #3 was a [AGE] year-old, male and admitted on [DATE] and 02/20/24 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (is weakness or the inability to move on one side of the body) following cerebral infarction affecting right dominant side, and need for assistance with personal care. Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS indicated Resident #3 had a BIMS score of 11 which indicated moderate cognitive impairment. The MDS indicated Resident #3 did not reject care. The MDS indicated Resident #3 was dependent for shower/bathe self. Record review of Resident #3's care plan dated 01/24/24 indicated Resident #3 had an ADL self-care performance deficit. Intervention included bathing required two staff for assistance. Record review of Resident #3's ADL bathing report dated 05/2024 indicated no documentation for Resident #3 for 4 (05/04, 05/14, 05/18, 05/23) out of 13 scheduled bath/showers. The ADL bathing report indicated Resident #3 's shower days were Tuesdays, Thursdays, and Saturdays on day shift. Record review of Resident #3's ADL bathing report dated 06/2024 indicated no documentation for 4 (06/03, 06/05, 06/07, 06/10) out of 5 scheduled bath/showers. The ADL bathing report indicated Resident #3's shower days were Mondays, Wednesdays, Fridays on day shift. Record review of Resident #3's shower list sheets dated May-June 2024 indicated: *05/21/24 Shower by CNA A *05/25/24 Shower by CNA A *05/29/24 Shower by CNA A *06/05/24 Shower by CNA A During an observation and interview on 06/12/24 at 12:40 p.m., Resident #3 said if he did not ask for his scheduled showers, and the aides did not give them. He said so sometimes he did not get his showers. He said he was supposed to get showers three times a week. He said some aides did their job and others did not or did not show up for work. He said Resident #2, his roommate, raised hell when he did not get his showers. He said it was frustrating not get his showers or he must ask for them when it was the same schedule every week. Resident #3 appeared to have slightly oily hair. During an interview on 06/12/24 at 4:20 p.m., CNA C said she had been working at the facility for a year. She said CNAs were responsible for giving residents their showers or bed baths. She said most residents got showers unless they were hospice. She said shower or bed baths were scheduled three times a week. She said the aides charted when the showers or bed baths were done in the facility's charting system and initialed the shower list. She said giving the residents their showers or bed baths were important for hygiene. She said the resident should not smell. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 3 of 5 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 06/19/2024 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 - Some During an interview on 06/12/24 at 4:29 p.m., CNA D said she had worked at the facility for two years. She said showers and bed baths were scheduled three times a week. She said the CNAs were responsible for giving the residents their showers and bed baths. She said the aides documented in the facility's computer charting system and initialed the shower list when completed. She said it was important to give residents their showers and bed baths for skin care, maintain their appearance, make them feel better, and reduce odors. She said not getting scheduled showers and bed baths could make the residents feel embarrassed. She said the residents were dependent of the staff to give them care. During an interview on 06/12/24 at 4:50 p.m., LVN E said she had worked at the facility for a year. She said she had worked all the halls and had worked with Resident #1, Resident #2, and Resident #3. She said the CNAs were responsible for giving the residents their showers and bed baths. She said nurses should make sure the showers and bed baths were getting done on schedule. She said resident's showers and bed baths were scheduled three times a week. She said showers and bed baths were important for skin care and hygiene. She said residents not getting their scheduled showers and bed baths could cause skin breakdown or odors. During an interview on 06/12/24 at 5:20 p.m., the DON said she felt like the residents were getting their scheduled bed baths and showers. She said the residents' showers or bed baths were scheduled three times a week. She said Resident #1 would not take a shower, so he got bed baths. She said if Resident #1 did not get his bed bath, he would let someone know. She said she felt the missing documentation was a charting issue in the system. She said the staff member who usually made sure the aides were documenting, had been out for medical reasons. During an interview on 06/12/24 at 5:33 p.m., the AIT said residents' showers and bed baths were scheduled three times a week and if a resident requested one. She said the CNAs were responsible for providing the showers and bed baths, but any trained staff members could do it. She said the ADON and DON should be supervising the staff to ensure residents received their scheduled showers and bed baths. She said providing scheduled and requested showers and bed baths were important for cleanliness, dignity, and overall psychosocial wellbeing. During an interview on 06/12/24 at 5:45 p.m., the Interim ADM said the CNAs were responsible for providing the resident their showers and bed baths. He said all nursing staff members should monitor the CNAs to ensure the showers and bed [NAME] were being done. He said residents getting their scheduled showers and bed baths needed to be monitored more and it started at the ADM position. He said if residents refused showers or bed baths, then the residents should be encouraged to get one. He said the facility had conversation with the CNAs on giving residents their showers. He said showers and bed baths were important for the resident's dignity, hygiene, and skin integrity. He said not receiving showers and bed baths affected the residents physically and emotionally. During an interview on 06/14/24 at 11:45 a.m., CNA A said she worked with Resident #1, Resident #2, and Resident #3. She said the resident's showers were scheduled three times a week. She said the showers were either MWF or TThSat. She said she tried her best to give the residents their scheduled showers. She said when showers and bed baths were completed, the aides documented in the facility's computer charting system and initialed the shower list. She said a nurse also signed the shower list verifying the resident showers were done. She said dayshift had enough staff to give the residents their scheduled showers and bed baths. She said Resident #1 was a bed bath and Resident #2 and Resident #3 took showers. She said Resident #2 was on night shift but was on day shift at that time. She said she was not sure why Resident #2 had switched to day shift for his showers. She said it was important to give residents their scheduled showers and bed bath, so they felt better and hygiene. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 4 of 5 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 06/19/2024 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 said not receiving scheduled showers or bed bath could cause depression. Level of Harm - Minimal harm or potential for actual harm Record review of an undated facility's Bath, Tub/Shower policy indicated .bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation .although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed .the resident will experience improved comfort and cleanliness by bathing .the resident will maintain intact skin integrity .the resident will be free from soil, odor, dryness, and pruritus following bathing . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 5 of 5