Health inspection·October 3, 2024

F 0812 (1) individual cup of 2 pints of cranberry juice was not labeled and had no preparation date. Level of Harm - Minimal harm or potential for actual harm (4) individual cups of 4 ounces of nectar orange juice were not labeled and had no preparation date. (39) individual cups of 4 ounces of regular orange juice were not labeled and had no preparation date. Residents Affected - Some (30) individual cups of 4 ounces of white milk were not labeled and had no preparation date. (10) individual cups of 4 ounces of cranberry juice were not labeled and had no preparation date. (10) individual cups of 4 ounces of apple juice were not labeled and had no preparation date. During an observation of kitchen freezer 1 of 3 on 10/3/24 at 11:01 a.m., the following were observed: -(4) premade frozen pancakes were not bagged, not labeled, had no open date, and no receive date. During an observation of kitchen freezer 2 of 3 on 10/3/24 at 11:01 a.m., the following were observed: -(1) bag of frozen chocolate chip cookies was not bagged, had no label, had no open date, and no expiration date. During an observation of the kitchen on 10/3/24 at 11:06 a.m., the following were observed underneath the dishwasher mat: -The State Surveyor observed food debris under the mat and 3 baby roaches crawling on the floor. -Dietary Manager stated she was getting someone to clean underneath the dishwasher mat. -Dietary Manager was observed stepping onto the baby roaches killing them as she saw them crawling on the floor. During a walk-through interview in the kitchen with the Dietary Manager on 10/3/24 at 11:01 a.m., the Dietary Manager stated once food was prepared it was good for 7 days and the expired foods should have been discarded. The Dietary Manager stated the freezer items should have been labeled and placed in a sealed zip lock bag before being placed back into the freezer. The Dietary manager stated it was important to ensure food items were labeled and dated to prevent sickness to the residents. During a phone interview on 10/3/24 at 1:53 p.m., [NAME] A stated she had been employed at the facility for 6 years. [NAME] A stated she worked 530 a.m. to 12:30 p.m. [NAME] A stated all food items in the refrigerator were to be labeled, dated with received date, open date, and expiration date. [NAME] A stated that her hours were cut and that she had hurried to do everything, so she did not label or date the food items found in the refrigerator. [NAME] A stated that the evening shifts were to make sure that all items in the freezer were sealed. [NAME] A stated the premade pancakes fell on the morning shift but the night crew had pancakes one night and she did not touch the pancakes in the freezer unsealed and not labeled. [NAME] A stated all staff were responsible for making sure freezer (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 10/03/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm items were resealed in bag, labeled, and dated. [NAME] A stated that the facility had hired new staff and they had gone through training, but when it came to labeling and dating foods and resealing freezer foods, the new staff had not followed their training. [NAME] A stated the Dietary Manager oversaw her. [NAME] A stated, It was important to ensure staff were labeling, dating, and resealing refrigerator and frozen food items so the residents would not get sick with contaminated food items. Residents Affected - Some During an interview on 10/3/24 at 1:46 p.m., the Dietary Manager stated she had been the dietary manager for five years. The Dietary Manager stated she oversaw the dietary staff. The Dietary Manager stated all food items in the refrigerator were to be labeled, dated with received date, open date, and expiration date. The Dietary Manager stated in the past staff had completed in-services on labeling and dating all food items. Dietary Manager stated she was not sure when the last in-service on labeling and dating was last completed with the Dietary staff. The Dietary Manager stated staff would be doing another in-service soon on labeling, dating, and resealing freezer food items. The Dietary Manager stated she conducted a walk-through in the kitchen every day. The Dietary Manager stated she did not conduct a walk-through the kitchen today. The Dietary Manager stated she did not do a walk through today because she had been cooking in the kitchen. The Dietary Manager stated the Administrator did not conduct a walk-through in the kitchen. The Dietary Manager stated the Corporate Administrator walked through the kitchen once a month. The Dietary Manager stated, It was important to ensure staff were labeling, dating, and resealing refrigerator and frozen food items so food wound not be freezer burnt and go bad. During an interview on 10/3/24 at 2:02 p.m., the Administrator stated she had been the Administrator since July 12, 2024. The Administrator stated she conducted daily walk-throughs in the kitchen. The Administrator stated she did check the refrigerator and freezer during her walk-through. The Administrator stated she would create a check list to use when conducting her walkthroughs. The Administrator stated it had been a few months since staff completed in-services on labeling, dating, and resealing refrigerator and resealing freezer items. The Administrator stated she was not aware of the expired food items found in the refrigerator. The Administrator stated she was not aware of the freezer items found in the kitchen not sealed or labeled. The Administrator stated she oversaw the dietary manager. The Administrator stated that the dietary staff, Dietary Manager, and she were all responsible for ensuring the food items found in the kitchen were dated and labeled correctly, as well as discarding expired food. The Administrator stated, It was important to ensure staff were labeling, dating, and resealing refrigerator and frozen food items because it was best food practices to alleviate improper food storage and ensure safety to prevent illness to the residents. Record Review of the facility's Dietary policy titled Food Storage dated 2012, indicated all facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. (4) Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened; (7) 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 (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 10/03/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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; (7) According to the USDA fact sheet on Food Product dating, ( www. fsis.usda.gov/wps/portal/fsis/topics/food-safety education/get-answers/food-safety-fact- sheets) product dating on manufactured goods is not required by federal regulations except baby formula. For this reason, products without a dated shipping label should be dated when they are received by the facility so there is a method to keep track of the age of the product. These dates do not indicate that the product is no longer safe after one year but give a method to track the age of a product so that it can be evaluated for quality before service. (9) These non-perishable foods are still dated when received if they do not have an expiration date and once opened, but do not need to be discarded within 7 days after opening. Record Review of FDA Food code dated 2022 indicated, 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents. (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with (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 10/03/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. Event ID: Facility ID: 675177 If continuation sheet Page 5 of 5