Health inspection·October 31, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 10/31/24 at 9:10 AM, Resident #1 was lying in his bed in his room. He said he was unable to open his hand and extend his fingers. He said his hand was contracted and it began when he had an accident prior to admitting to the facility. There was no splint or device in his contracted hand. During an interview on 10/31/24 at 9:28AM, Family member A said the facility was not doing anything for Resident #1's right-hand contracture. She said the facility was not using a splint or any device. During an interview on 10/31/24 at 10:05AM, LVN B said he was the bedside nurse for Resident #1 this day. He said he was not aware if Resident #1 was supposed to have a splint, roll, or rag for his contracted hand. He said he thought it was worth a try to put something in Resident #1's hand to prevent worsening of his contracture. He said Resident #1 was not receiving therapy. During an interview on 10/31/24 at 10:10AM, CNA C said she was taking care of Resident #1 this day. She said she did not do any range of motion exercises with him, and there was not a splint or roll that was supposed to be in his hand. During an interview on 10/31/24 at 10:32AM, Rehab Director D said Resident #1 was not receiving therapy services at that time. She said since he was not on therapy services, she expected the nursing staff to make sure his contracture was treated to prevent the contracture worsening. During an interview on 10/31/24 at 10:40AM, the DON said she usually put a rag or a roll in Resident #1's hand for his contracture. She said she had not yet put the roll in his hand this morning before this surveyor interviewed him. She said she had not obtained an order for the rag or roll for his contracture. She said the risk was that it was possible that a nurse unfamiliar with his care might not realize he had a contracture and not put the roll in his hand. She said she had asked him before about putting a splint in his hand, but he refused the splint because he would not have been able to use his fingers with his tablet. She said she was going to put an order in the system after this interview was completed. 2. Record review of Resident #2's face sheet, dated 10/31/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included right hand contracture (A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), and Alzheimer's disease (a brain disorder that causes a gradual decline in memory and thinking skills). Record review of Resident #2's annual MDS assessment, dated 10/22/24, indicated she had a BIMS score of 07, which indicated severe cognitive impairment. She was able to make herself understood and she was able to understand others. She required setup assistance with eating. She required supervision or touching assistance with eating and personal hygiene. She required moderate assistance with upper body dressing. The MDS assessment further indicated she had impairment on one side of her upper extremities. Record review of Resident #2's care plan, last revised on 08/09/24, indicated the care plan did not address any device for Resident #2's right hand contracture. Record review of Resident #2's physician's orders, dated 10/31/24, indicated this order: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 2 of 4 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 10/31/2024 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few *Soft/rolled fabric to right hand for 4 hours a day or as tolerated further hand fisting and skin breakdown. Every day and night shift. The start date was 10/17/24. During an observation and interview on 10/31/24 at 11:40AM Resident #2 was lying in bed in her room. She said she did have a contracted right hand. She said the facility did sometimes put something in her hand for her contracture, but they had not in about a month. She said she wished they would do it more often if it would help prevent the contracture getting worse. She said she was not sure who put something in her hand before. She said she did not receive therapy. She did not have anything in her hand. During an interview on 10/31/24 at 11:42AM, LVN B said he was not aware if Resident #2 was supposed to have something in her hand for her contracture. He said it would not hurt to try to put something in her hand. During an interview on 10/31/24 at 11:44AM, CNA C said she was not aware if Resident #2 was supposed to have something in her hand for her contracture. She said she had not put anything in her hand that day and she had not done anything for that hand that day. During an interview on 10/31/24 at 11:46AM, the DON she has tried putting a rag in Resident #2's hand before but she either pulled it out or complained that it was hot. She said she would speak with therapy about an alternative that could work better for Resident #2. She said the charge nurse was responsible for ensuring that something was placed in Resident #2's hand as the physician's order stated. During an interview on 10/31/24 at 12:07PM, the Administrator said her expectation for contractures was that the orders and policy should be followed. She said any contractures or potential contractures should be brought up and discussed with the IDT so that orders can be added if they are not already present. She said the risk was that the contracture could worsen and cause physical immobility. Record review of the facility's undated policy, Immobilization Devices, Splints/Slings/Collars/Straps, stated: Immobilization devices are splints, slings, cervical collars and clavicle straps that are applied to restrict movement, support and preserve the integrity of an injured arm, shoulder or neck. Splints are rigid devices that can be used to treat a bone fracture, dislocation, or to prevent further damage of bones, joints and muscles following injury or during acute phases of chronic diseases such as arthritis. Splints are also used to treat contractures .Procedure 1. Review Physician[']s order. Perform hand washing. 2. Explain purpose of procedure and expected results to the resident . .4. If a splint is applied: 1. Select a splint that will fit the body part and immobilize the joint above or below the fracture or injury. If the splint is used for arthritis, it should fit around the inflamed joint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 3 of 4 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 10/31/2024 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)

F 0688 2. Pad the splint if needed. Position and adjust with the body part in alignment. Level of Harm - Minimal harm or potential for actual harm 3. Secure with Velcro, strips of cloth, pin, or tape the loose end. Secure the material with firmness but without compromising circulation. Residents Affected - Few 4. Remove the splint periodically to assess skin and maintain cleanliness and dryness under the splint. 5. If handroll is used 1. Position the handroll between the fingers and palm of hand 2. Do not hyperextend the joints when inserting the handroll . .15. Document all care and the resident[']s response to treatment in the clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675177 If continuation sheet Page 4 of 4