Health inspection·July 31, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 5 residents reviewed for resident rights. (Resident #1) The facility failed to ensure staff assisted Resident #1 when answering his call light by turning his call light off and not returning to provide assistance. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of quadriplegia (the paralysis of both arms and legs due to various conditions, such as spinal cord injury, stroke, or cerebral palsy), anxiety, and seizures (uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). Record review of the significant change MDS assessment dated [DATE] revealed Resident #1 had a BIMS of 14, which indicated his cognition was intact. Resident #1 required set up assistance for eating and oral hygiene and was dependent for staff for bed mobility and transfers. Record review of a care plan dated 09/12/2022 titled ADL assistance indicated Resident #1 had an ADL self-deficit related to quadriplegia. The intervention for Resident #1 revealed the staff was to encourage the resident to use his call light for assistance with ADLs. During an interview on 07/29/2024 at 1:00 p.m., Resident #1 stated he had a concern with the number of times the staff will come into the room and turn his call light off and tell him they would return and not return. He stated it happens nearly daily but had started to be a routine around the 1st of the year and he had made a grievance with the Administrator about these occurrences. He stated the CNA that did it daily quit working at the facility a few months back, but there was still CNAs that turned his light off and did not return. He stated he gave them time once they turned his light off before he turned it back on, but often they would come back in and turn it off again and walk out. He stated he would need anything from ice to be turned or a light turned on or off and they would not return to help him. He stated it made him feel angry and disrespected when his light was turned off and he had to wait on a different person to assist him with his needs. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675177 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 07/31/2024 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)