Inspection·June 7, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with dignity to avoid embarrassment and expects all staff to follow facility policy and procedures for maintaining dignity. During an interview on 06/07/23 at 1:09 PM the Admin stated everyone was responsible for ensuring resident privacy and dignity. He stated the resident could be affected psychosocially and make them uncomfortable if their dignity and privacy were not maintained. He stated his expectation going forward was that all residents are cared for with privacy and dignity. Record review of facility policy and procedure titled Resident Rights dated August 14, 2022, indicated' .the staff will abide by and protect resident rights in accordance with state and federal guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 2 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 9 of 12 months (May 2022, June 2022, July 2022, August 2022, October 2022, December 2022, January 2023, February 2023, and March 2023) reviewed for pharmacy services. The facility did not have a licensed pharmacist and two witnesses initial the attached pages of controlled medication destruction inventory sheets. This failure could put residents at risk for misappropriation and drug diversion. Findings: During a record review of the facility's drug destruction log for the last 12 months, the drug destructions for controlled drugs dated 05/24/22, 06/24/22, 07/26/22, 08/26/22, 10/21/22, 12/16/22, 01/13/23, 02/08/23, and 03/10/23 indicated that the attached pages of medication destruction did not include the initials of the consultant pharmacist and two witnesses. During an interview on 06/07/23 at 9:50 a.m., the ADON said that she was unaware that there had to be two witnesses initialing each page and that she thought the cover sheet was all that was needed. She said that she took this position in late 2022 and would implement a new system that would ensure all attachment pages were witnessed appropriately going forward. During an interview on 06/07/23 at 9:55 a.m., the DON said that she was unaware of the need for each attachment page to be witnessed by two witnesses. She said that she would ensure all pages were signed and initialed appropriately going forward. She said that she did not think a drug diversion could happen and could not think of any negative outcomes that could occur. During an interview on 06/07/23 at 1:14 p.m., the ADMIN said that he would check the regulations with the pharmacist to ensure the drug destruction occurred appropriately, and said that going forward, he expected his staff to follow correct policy regarding drug destruction. Record review of facility policy titled Disposal of medications, syringes, and needles: Disposal of Medications dated 2007 indicated .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal and state laws and regulations . Record review of 22 TAC §303.1 Destruction of Dispensed Drugs accessed online 06/07/2023 at https://texreg.sos.state.tx.us/ indicated; (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 3 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0755 Level of Harm - Minimal harm or potential for actual harm health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. Residents Affected - Some (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (iii) date of drug destruction. (iv) date the prescription was dispensed; (v) unique identification number assigned to the prescription by the pharmacy; (vi) name of dispensing pharmacy; (vii) name, strength, and quantity of drug; (viii) signature of consultant pharmacist destroying drugs; (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). v) any two individuals working in the following capacities at the facility: (I) facility administrator; (II) director of nursing; (III) acting director of nursing; or (IV) licensed nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 4 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. Residents Affected - Many The dish machine tested at 10 ppm of chlorine and the temperature gauge was stuck at 110 degrees F. The grease in the deep fryer was black. These failures could place the residents at risk of foodborne illnesses. Findings include: During an observation and interview on 06/05/23 at 9:04 AM surveyor entered the kitchen and noted the calendar log for the dish machine had not been completed for 06/05/23, and the sanitizer bottle attached to the dish machine was empty. Dietary Staff F was standing at the dish machine, and it was running washing dishes. The surveyor requested staff to test the dish machine. Nutrition Aide F tested the dish machine with Auto-Chlor precision chlorine test strip. The machine tested at 10 ppm and the thermometer on the dish machine never moved off 110-degrees F. Nutrition Aide F showed the test strip to the surveyor, and she was unable to tell the surveyor what correct reading the test strip should read. (50-100 ppm). The temperature of the water should reach 120 degrees F. during the final rinse. Nutrition Aide F said she had worked at the facility for 28 years and was taught to test the dish machine by the previous dietary manager. Nutrition Aide G attempted to test the dish machine and it tested at 10 ppm. She showed the test strip to the surveyor and did not know what it should read. Nutrition Aide G said she has worked at the facility for five years and was taught to test the machine by the previous dietary manager. During an observation on 06/05/23 at 09:15 AM, the grease in the deep fryer was black. During an interview on 06/05/23 at 9:18 AM the Dietary Manager said they usually changed the oil in the fryer every two weeks. She said they change the oil after they fry fish. Black oil indicates the oil is dirty and could become rancid. During an interview on 06/06/23 at 9:20 AM, The DM said they did not have any cooking oil available to change the oil in the fryer over the weekend. She said they usually change it on Saturday or Sunday after they fry fish on Friday. She said she had to go to the store and buy oil to change the grease in the fryer. She said not changing the oil could make the residents sick. During an interview on 06/06/23 at 9:15 AM with the Dietary Manager she said that she usually tested the dish machine herself first thing every morning, but she had not gotten to it yet. She said her expectation for the dish machine was for the staff to be able to correctly test the dish machine as required. She said they called ECO-Lab, and they came out and replaced the thermostat on the dish machine this morning. She said the dish machine not sanitizing the dishes could make the residents sick. During an interview on 06/07/23 at 1:30 PM, the Administrator said his expectations was for the kitchen staff to follow the policy and keep the dish machine in working order and check the sanitizer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 5 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 and temperature of water at the start of use. Level of Harm - Minimal harm or potential for actual harm Record review of a policy, Titled: Cleaning Dishes in the Dish Machine, effective August 1, 2018 reflected: Dishes and cookware are washed and sanitized after each meal. Residents Affected - Many Procedure: 1. Check the dish machine gauges and chemicals at the start and throughout the use to ensure proper temperatures/adequate supply, respectively. Log data as instructed. Refer to the manufacturer's directions for correct temperature and sanitizer (low temperature dish machine only) setting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 6 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 maintain and ensure safe and sanitary storage of residents' food items for 2 of 16 resident personal refrigerators reviewed for food safety (Resident #315 & Resident #11). Residents Affected - Few The facility failed to ensure the refrigerator for Resident #315 had a thermometer for checking the temperature and that the refrigerator for Resident #11 did not contain an unlabeled, undated sandwich, or expired cranberry juice. This failure could place residents at risk for food borne illnesses. Findings include: Record review of a resident face sheet dated 6/7/23 indicated that Resident #315 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease (COPD), Heart failure, unspecified, and opioid dependence, uncomplicated. Record review of a BIMS assessment dated [DATE] for Resident #315 indicated that he had a BIMS score of 15 indicating that the resident was cognitively intact. Record review of a face sheet dated 6/7/23 indicated that Resident #11 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Cerebral infarction, End stage renal disease, Type 2 diabetes mellitus, and Dependence on renal dialysis. Record review of a comprehensive MDS dated [DATE] for Resident #11 revealed that she had a BIMS score of 15 indicating that she was cognitively intact. During an observation and interview on 06/05/23 at 09:35 a.m., Resident #315's personal refrigerator was observed with no thermometer to allow staff to check temperature. Resident #315 stated that he was unaware if any staff had checked his refrigerator as he had only admitted to the facility a few days ago and the refrigerator was in the room when he admitted . The refrigerator was observed to contain several protein shakes. During an observation on 06/05/23 at 10:17 a.m., Resident #11's personal refrigerator was observed with a sandwich in an open plastic bag with no date and no label. Bread on the sandwich was hard; also observed a bottle of cranberry juice with an expiration date of April 17, 2023. During an interview on 06/05/23 at 11:00 a.m. the DON was unable to say who was responsible for checking resident refrigerators for temperature and expired food items. During an interview on 06/07/23 at 10:11 a.m. the HSK supervisor said that she was responsible for checking the temperatures in resident refrigerators, but that some days she did not have time to do it. She said that she does keep a log when she checks the temperatures. She said that she was unaware until yesterday that she was also responsible for cleaning out the refrigerators in resident rooms and ensuring that all expired foods were disposed of. She said that she would be doing that going forward. She said that residents could be at risk of consuming ruined foods if the refrigerator was not keeping foods at the correct temperature or if they consumed expired foods. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 7 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0813 Level of Harm - Minimal harm or potential for actual harm During an interview on 06/07/23 at 09:55 a.m., the DON said that if the temperature checks on resident refrigerators were not done appropriately and the temperature started fluctuating and no one realized it, that it could potentially cause food spoilage and food borne illnesses. She said that housekeeping was responsible for checking the temperatures in resident refrigerators and going forward would be responsible for disposing of expired food items. Residents Affected - Few During an interview on 06/07/23 at 01:14 p.m., the ADMIN said that he expected that his staff would routinely check the temperatures in resident refrigerators to prevent residents from getting sick. Record review of temperature logs for June 2023 indicated that the refrigerator in Resident #315's room had not had a temperature check for the months of April, May, or June. Record review of facility policy titled Storage and Handling of food from outside sources dated August 1, 2018, indicated .The facility will record routine temperature logs and provide cleaning and sanitation as necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 8 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident # 24, Resident # 35, and Resident #60) reviewed for infection control. Residents Affected - Some 1. CNA A failed to properly handle soiled linen and soiled brief for Resident #24 after personal care. 2. CNA B failed to properly handle soiled linen and soiled brief for Resident #60 after personal care and failed to appropriately perform hand hygiene after incontinent care. 3. Treatment nurse failed to clean the scissors used to cut wound care dressings for Resident #35 and she stored the scissors in her pocket. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: 1. Record review of facility face sheet dated 6/06/2023 indicated Resident # 24 admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypercapnia (impaired breathing that causes increased carbon dioxide in the blood). An admission MDS dated [DATE] indicated Resident #24 had a BIMS of 10 indicating moderate cognitive impairment and required maximum assistance with bathing and toileting. A Care plan dated 04/11/2023 indicated a self-care deficit and required assistance with self-care. During an observation on 06/05/23 at 09:57 AM Resident #24 was receiving personal care from CNA A. During an observation on 06/05/23 at 10:06 AM Resident # 24 had soiled linen including a bed sheet, incontinent pad, and a soiled brief on the floor bedside their bed. During an interview on 06/05/23 at 10:21 AM CNA A stated she had been a CNA for 5 years. She stated when she provided incontinent care to Resident #24, she should have placed her soiled linen and soiled brief in a bag to prevent contaminating the floor in the resident's room. She stated she had been trained on proper handling of soiled linens annually and by not doing so could be an infection control issue for the resident and others. 2. Record review of facility face sheet dated 6/06/2023 indicated Resident # 60 admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (impaired breathing that causes low oxygen to the brain), severe sepsis (infection in the body), and urinary tract infection. An admission MDS dated [DATE] indicated Resident #60 had a BIMS of 08 indicating moderate cognitive impairment and required extensive assistance with transfers, dressing, and toileting. A Care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 9 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0880 dated 05/04/2023 indicated a self-care deficit and required extensive assistance. Level of Harm - Minimal harm or potential for actual harm During an observation on 06/05/23 at 10:12 AM Resident #60 received incontinent care from CNA B. CNA B placed soiled wet washcloths and towels on the floor beside the resident bed and did not change her gloves after providing incontinent care. CNA B wore the same soiled gloves to dress and transfer Resident #60 into her wheelchair. Residents Affected - Some During an interview on 06/05/23 at 10:41 AM CNA B stated she had been a CNA for 1 year. She stated she should have had a bag for her dirty linens and placed the soiled washcloths and towels in a bag not on the resident's floor. She stated she should have removed her gloves after incontinent care, washed her hands, and applied clean gloves before applying a clean pullup, dressing the resident, and transferring her to the wheelchair. She stated she had been trained on infection control measures including handling soiled linens. She stated the risk of not following infection control measures could be increased risk of infection to the resident. During an interview on 06/07/23 at 09:01 AM the IP nurse stated she oversees the infection prevention program and staff training. She stated all nursing staff are trained on hire, annually and as needed regarding infection control measures. She stated staff should change their gloves after incontinent care, wash their hands and then apply new gloves before performing the next task. She stated all soiled linen should be disposed of using standard precautions and not placed on the floor. She stated the risk of not following infection control measures would be cross contamination. She stated she expected all staff to following the training they have had and will begin retraining all staff. 3. Record review of a face sheet dated 6/6/2023 for Resident #35 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of nutritional deficiency (body does not get enough vitamins and minerals), anorexia (loss of appetite for food), hypertensive chronic kidney disease (damage to the kidney caused by high blood pressure), and hypertension. Record review of active physician orders dated 5/17/2023 for Resident #35 indicated an order to clean a wound to the sacrum (tailbone) and lower back with normal saline or wound cleanser, pat dry, cover wound bed with calcium alginate (an absorbent wound dressing that promotes healing) and cover with dry dressing every shift until resolved. Record review of a care plan for Resident #35 dated 6/6/2023 indicated she had skin breakdown as evidenced by stage 4 (deep wound reaching the muscles and bones) to her sacrum and lower back with interventions to cleanse stage 4 to lower back and sacrum with normal saline or wound cleanser, pat dry, cover wound bed with calcium alginate and cover with dry dressing until resolved daily. Record review of a Quarterly MDS assessment dated [DATE] for Resident #35 indicated she had severe impairment in thinking with a BIMS score of 3. She required total dependence with personal hygiene with one person assist. She had two pressure ulcer/injuries at stage 4. During an observation on 6/6/2023 at 10:00 AM, the Treatment nurse provided wound care to Resident #35. The Treatment nurse gathered supplies in the hallway prior to entering Resident #35's room and placed the items on a tray. Wound care was provided to Resident #35's sacrum and lower back. LVN washed and sanitized her hands, and wore gloves throughout the treatment. The Treatment nurse removed scissors from her pocket and cut the calcium alginate to fit the wound and placed it on Resident #35's lower back and sacrum without cleaning them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 10 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/6/2023 at 10:20 AM, the Treatment nurse said she had been employed at the facility since January 16, 2023. She said she had received training on wound care from the previous ADON and the IP. She said she should have sanitized her scissors before the treatment and placed them on the tray and not have them in her pocket. She said she should have precut the calcium alginate beforehand. She said corporate staff did checkoffs with her on basic dressing and wound care in February 2023. She said a resident could be at risk for contamination from the scissors being in her pocket and cutting the dressing before cleaning them. She said it could cause an infection. Record review of a facility training for the Treatment nurse dated 2/22/2023 indicated she had a competency skills checkoff on infection control for wound care training by the Regional nurse consultant. During an interview on 6/6/2023 at 10:30 AM, the IP nurse said she had been employed at the facility since July 2022. She said she did not train the treatment nurse on wound care and that the wound care training was done by the previous ADON. She said she did provide the Treatment nurse training on hand washing and infection control but not anything related to wound care. During an interview on 6/06/2023 at 11:35 AM, the DON said the Treatment nurse had been trained on wound care by the previous ADON. She said the treatment nurse had received a computer-based training on wound care and would be taking another online course on wound care soon. She said residents could be at risk for infection. She said going forward the treatment nurse would be enrolled in another wound care training and staff would receive more education on wound care. During an interview on 6/7/2023 at 11:00 AM, the Regional nurse said she had been at the facility since November 2022. She said she did train with the Treatment nurse on wound care and documentation. The Regional Nurse said she observed the Treatment nurse perform wound care treatments and was instructed on cleaning equipment before use such as scissors. She said scissors were never to be stored in the pockets of staff. She said a resident could be at risk of infection. During an interview on 06/07/23 at 09:06 AM the DON stated the IP oversees the staff training program and reviewed training and reports. She stated she expected all staff to follow standard precautions to avoid spread of infection. She stated she would see that all staff were retrained on infection measures. During an interview on 06/07/23 at 1:11 PM the Admin stated the DON was responsible for overseeing the infection control program and the IP was responsible for training. The risk to resident could be a negative effect from exposure to something that was infectious. The DON stated he expected that all staff follow infection control guidelines. Record review of undated facility policy titled Linens indicated, .The facility staff should handle all used laundry as potentially contaminated and use standard precautions. Contaminated laundry is bagged or contained at the point of collection. Record review of facility policy and procedure dated January 12, 2020, titled Perineal Care indicated' .Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection. 9. Dispose of gloves and used supplies and perform hand hygiene. 10. Apply new gloves and place new brief. Record review of a facility policy titled Treatment of Wounds: Dressing Changes dated July 2018 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 11 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0880 indicated, .2. Follow standard precautions and infection control methods . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 12 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0908 Keep all essential equipment working safely. 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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment. Residents Affected - Few The facility did not ensure the stove was in working order. Two of the six burners on the stove did not light, when the knobs were turned. DM turned knobs on for the middle burners to light (they did not) and left gas on, when the burners on the right side of the stove lit the [NAME] shot across the top of the stove and lit the middle burners. This failure could place the residents at risk of a fire and not having safe operating equipment. Findings included: During an observation on 06/05/23 at 9:12 AM, the DM was turning the knobs to light the burners on the stove. The middle burners on the stove did not light when the knob was turned. The DM had her head down close to the burners looking under a pot on the stove to see if the burner lit. When she turned the knob and lit the burners on the left side of the stove, the flames shot across the top of the stove and lit the middle burners. During an interview on 06/06/23 at 2:45 PM, the DM said she had the maintenance supervisor check the stove and he cleaned out the tubes and the pilot lights were staying lit now. She said it was her responsibility to notify the maintenance supervisor if equipment in the kitchen was not operating properly. She said the maintenance supervisor had just checked the stove last week and it was working fine. She said she was not aware it was not working at time of survey. She said if the gas builds up it could cause a fire or for someone to get burned. A policy Title: Equipment Maintenance, not dated, indicated: 1. The maintenance director is responsible for ensuring the building, grounds and equipment are maintained in a safe and operable manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 13 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 21 residents reviewed for call lights. (Resident #6 and Resident #316). Residents Affected - Few The facility failed to ensure Resident #6 and #316's emergency call light in the bathroom would reach the floor. The call light cord for Resident #6 was too short and Resident #316's was wrapped around the support bar. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings include: Record review of a face sheet dated 6/6/23 indicated that Resident #6 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, Chronic obstructive pulmonary disease, and Type 2 diabetes. Record review of a Quarterly MDS dated [DATE] for Resident #6 indicated that she had a BIMS score of 15 indicating that she was cognitively intact. MDS Section G indicated that the resident required supervision and setup help only for toilet use. Record review of a face sheet dated 6/7/23 for Resident #316 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Repeated falls, chest pain, Gastro-esophageal reflux disease, and Chronic obstructive pulmonary disease. Record review of a comprehensive MDS dated [DATE] indicated that Resident #316 had a BIMS score of 03, indicating severe cognitive impairment. MDS section G indicated that the resident required maximum assist of two or more persons to use the toilet. During an observation on 06/05/23 at 10:08 a.m. the call light in the restroom of room [ROOM NUMBER] (Resident #6's room) was observed to be too short, and the end of the string ended above the grab bar. During an interview on 06/05/23 at 12:25 p.m., Resident #6 said that she used the restroom independently. She said she had not fallen, but if she were on the floor that she would not be able to reach the string to pull the light. During an observation and interview on 06/05/23 at 09:40 a.m. the call light in room [ROOM NUMBER] (Resident #316's room) was observed to be wrapped around the grab bar in the restroom. Resident #316 said that it had been like that since he had been admitted on [DATE]. He said that if he fell, he would not be able to reach the string to pull it. During an interview on 06/05/23 at 04:15 p.m., CNA E said that staff were always in the restroom with Resident #316, and he would never be in there alone. She said that Resident #6 used the restroom independently. Upon observing the call light in the restroom of Resident #6, she said that if the resident were to fall, she would be unable to reach the string to call for help. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 14 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/05/23 at 04:19 p.m. the maintenance director said that he was responsible for ensuring call lights in restrooms were accessible. He said that if the resident fell, she would be unable to reach the call light and call for help if the string were too short. During an interview on 06/07/23 at 01:14 p.m. the ADMIN said that going forward, he would expect his staff to ensure all call lights were accessible to residents and in proper working order. He said that if residents were not able to reach the call light, it could delay them getting the help they needed. Record review of facility policy titled Safety systems for residents with a date of January 12, 2020, indicated .Call light is in place and attached within reach of resident at all times . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 15 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0926 Have policies on smoking. 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 follow established policy regarding smoking, smoking areas, and smoking safety for 1 of 6 residents reviewed for smoking (Resident #53). Residents Affected - Few The facility failed to keep cigarette butts out of the trash can in the smoking area (Front Porch of the Facility), and there were no ash trays or a red metal trash cans available for residents to extinguish their cigarettes. The residents were putting there cigarettes out on the bricks of the building. The residents were then placing the cigarettes in a plastic garbage can with paper goods in it This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings included: Record review of the Face Sheet dated 07/13/21, indicated Resident #53, admitted [DATE], was [AGE] years old with diagnosis of Schizophrenia (mental Disorder), Atherosclerotic heart disease of native coronary artery, (hardening of the arteries), Anemia, Essential (primary) hypertension, (high blood pressure). Record review of a Quarterly MDS assessment for Resident #53 dated 4/8/23 indicated he had a moderate impairment in thinking with a BIMS score of 12. A BIMS of 8-12 indicates the resident is moderately impaired. Record review of the care plan for Resident # 53 dated 4/14/23 indicated he was a smoker with interventions of safe smoking assessment as needed, staff supervision and he was an unsafe smoker. Counseled on designated smoking areas. During an observation on 06/05/23 at 1:55 PM the front porch of the facility was designated as a smoking area. There were no ash trays or red trash cans available for residents to extinguish their cigarettes. There was a large plastic trash can with cigarette butts and paper in the trash can. During an interview on 06/06/23 at 2:30 PM with Resident #53 he said they only smoke out front on the porch when it is raining, otherwise they use the smoking gazebo, located out back. He said they use the bricks on the building to extinguish their cigarettes. During an observation on 06/07/23 at 11:20 AM of the smoking area on the front porch there were multiple ash marks on the bricks, and concrete near the sitting area. There were multiple burn holes in the cushions of the furniture. During an interview on 6/7/23 at 1:00 PM, the Administrator said that the front porch area was used for smoking by staff, residents, and visitors during bad weather. He said there was a fire extinguisher out on the front porch. The Administrator said there were no ash trays or a smoking can out there because he preferred, they used the smoking area out back. He said he was not aware that cigarettes were being put out on the side of the building. He said he was going to reevaluate the front of the building being used as a smoking area. He said there was a risk of fire and injury if the cigarettes were not extinguished properly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 16 of 17 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of a smoking risk assessment for Resident # 53 dated 4/6/23 indicated he was a safe smoker. Record review of a facility policy titled Smoking Policy, undated, reflected .Residents will smoke with appropriate supervision in the designated smoking area. The designated smoking areas are as follows: Front porch of the facility, smoking gazebo, located outside c hall exit and bench area/under tree outside c hall exit . Event ID: Facility ID: 675230 If continuation sheet Page 17 of 17