Inspection·February 14, 2024

F 0578 physician signed the form. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 10:31 AM, Resident #164 said he received hospice services and did not want CPR if he passed away. Residents Affected - Few During an interview on [DATE] at 01:25 p.m. the SW said she or the MR staff would obtain the DNRs. She said OOH-DNR forms should be complete with signatures, dates, and printed names or they would be invalid. She said Residents #50 and #164 would be deemed a Full Code indicating they would have CPR initiated. During an interview on [DATE] at 01:30 p.m. the MR staff said she and the SW would obtain the DNRs. She acknowledged Residents #50's OOH-DNR was missing the printed name of the agent initiating the form and #164's OOH-DNR was missing the date the physician signed it. She said Resident #164 brought the OOH-DNR form with him when he was admitted . She said it should have been reviewed upon admission for accuracy and completeness. During an interview on [DATE] at 03:05 PM, the DON said he was unaware of the inaccurate DNRs. He said the DNRs had to be complete, or they were invalid. He said these issues would make the residents a full code. He said as a result of an inaccurate DNR the residents would have lifesaving procedures performed when they did not want them. He said he would expect the DNRs to be completed when they were obtained and reviewed for completion if a resident were admitted and brought one with them. Record review of the Out-of-Hospital Do-Not-Resuscitate Order accessed on [DATE] at https://www.hhs.texas.gov/regulations/forms/advance-directives/out-hospital-do-not-resuscitate-ooh-dnr-order indicated on page 2: Instructions for Issuing An OOH-DNR Implementation: The OOH-DNR Order may be executed as follows: In addition, The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 2 of 13 residents (Residents #23 and #57) reviewed for MDS assessment accuracy. Residents Affected - Few * The facility did not accurately code Resident #23's MDS assessment for smoking. * The facility did not accurately code Resident #57's MDS assessment for weight loss. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1. Record review of a face sheet dated 02/13/24 indicated Resident #23 was a [AGE] year-old female admitted on [DATE]. Record review of the Baseline Care Plan dated 11/30/23 had no indication Resident #23 was a smoker. Record review of the Smoking Evaluation dated 12/04/23 indicated Resident #23 had not smoked cigarettes, pipe, cigar, tobacco, or used electronic vapor in the last 3 months. Record review of the admission MDS dated [DATE] indicated Resident #23 was marked yes for tobacco use. This section was signed by the MDS Coordinator on 12/07/23. During an interview on 02/14/24 at 09:55 a.m. the MDS Coordinator said she was working on 2 residents' MDS and she had mixed them up on the smoking section. She said Resident #23 should have been marked no for current tobacco use. 2. Record review of a face sheet dated 02/12/24 indicated Resident #57 was an [AGE] year-old female admitted on [DATE]. Record review of the EMR indicated Resident #57's weight on: * 11/30/23 was 146.2 lbs in a wheelchair; * 12/01/23 was 146.6 lbs in a wheelchair; and * 12/08/23 was 143.6 lbs in a wheelchair Record review of the MDS dated [DATE] indicated Resident #57 had a weight loss of 5% in one month or 10% in 6 months and was not on a physician-prescribed weight-loss regimen. This information was signed by the MDS Coordinator on 12/06/23. Resident #57 had not been in the facility for a month on 12/06/23. During an interview on 02/14/24 at 09:55 a.m. the MDS Coordinator said weight loss section was checked in error for Resident #57. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 0641 Level of Harm - Minimal harm or potential for actual harm During an interview on 02/14/24 at 11:45 a.m. the DON said he signed the MDS as completed. He said he did not check the accuracy of the MDS. He said he expected the staff who filled in the sections of the MDS to ensure the information was accurate. He said the inaccurate MDS could give an inaccurate picture of the residents' needs for care. Residents Affected - Few An MDS 3.0 Completion policy dated 02/13/24 indicated: Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 4. Care Plan Team Responsibility for Assessment Completion: a. Interdisciplinary Responsibility for Completion of MDS Sections: ii. Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 2 of 3 residents reviewed for PASRR (Residents #04 and #50). Residents Affected - Some * The facility did not have an accurate PASRR Level 1 Screening (P1) for Residents #04 and #50 upon admission therefore a PASRR Evaluation (PE) was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: 1. Record review of a face sheet dated 02/14/24 indicated Resident #04 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included anxiety and mood disorder. Record review of a PASRR Level 1 (P1) dated 06/01/21 indicated Resident #04 was negative for MI. During an interview on 02/14/24 at 09:45 a.m. the SW said she would fill out the P1 if a resident came from home and she was responsible for reviewing P1s from the hospital. She said she did not realize Resident #04's P1 was negative. She said anxiety disorder and mood disorder were diagnoses that would trigger for a positive P1 and require a PE to be done by the LMHA to determine if they meet criteria for PASRR. 2. Record review of a face sheet dated 02/13/24 indicated Resident #50 was a [AGE] year-old male admitted on [DATE]. His diagnoses included psychotic disorder with delusions (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) (delusions-belief or altered reality that is persistently held despite evidence or agreement to the contrary), anxiety disorder (persistent and excessive worry that interferes with daily activities), and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). Record review of the admission MDS assessment dated [DATE] indicated Resident #50 had active diagnoses of anxiety disorder, depression, and psychotic disorder. Record review of a P1 dated 08/24/23 indicated Resident #50 had dementia primary diagnosis marked no and MI was marked no. The P1 was done by facility SW. Record review of the EMR indicated Resident #50 had no PE. During an interview on 02/14/24 at 09:45 a.m. the SW said the diagnoses of psychotic disorder, psychosis, and anxiety disorder would trigger for a positive P1 and require a PE to be done. She acknowledged that she had marked on Resident #50's P1 that dementia was not a primary diagnosis. She said she should have marked his P1 yes for MI. She said she reviewed P1s when a resident admitted from the hospital. During an interview on 02/14/24 at 11:45 a.m. the DON said he did not routinely review the P1s but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 0645 Level of Harm - Minimal harm or potential for actual harm if he did notice one was not accurate then he would let the SW know so she could get it corrected. He said he expected the P1s to be correct when a resident admitted . A Resident Assessment-Coordination with PASARR Program dated 12/06/17 and revised 02/14/24 indicated: Residents Affected - Some Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. .6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice for 3 of 18 residents reviewed for respiratory care and services. (Residents #6, #265, and #314) Residents Affected - Some The facility failed to obtain a physician order for oxygen administration for Resident #6, Resident #265, and Resident #314. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of a face sheet dated February 2024 indicated Resident #6, admitted [DATE], was an [AGE] year-old female with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning) and hypertensive heart disease without heart failure (changes in the structure and function of the heart as a result of chronic blood pressure elevation with symptoms including shortness of breath). Record review of an admission MDS assessment dated [DATE] indicated Resident #6 had a BIMS score of 3 indicating severely impaired cognition and received oxygen therapy on admission and while a resident. Record review of an undated care plan indicated Resident #6 had an altered respiratory status/difficulty breathing with interventions included used oxygen continuously per physician orders. Record review of physician orders dated February 2024 did not indicate Resident #6 received oxygen therapy. During an observation on 02/11/24 at 10:45 a.m. Resident #6 was lying in bed wearing oxygen at 2.5 liters/minute per nasal canula (a device that delivers extra oxygen through a tube into the nose). During an interview on 02/13/24 at 2:45 p.m., LVN D said she was the nurse who admitted Resident #6. She said the resident arrived at the facility by ambulance and received oxygen at the time of admission. She said Resident #6 reported receiving oxygen during her hospital stay. She said she had left the supplemental oxygen order off the admission orders in error, and it should have been included. She said she was in-serviced on physician orders to include oxygen orders. She said not having an order for oxygen could result in the resident receiving too much or too little oxygen and the oncoming staff may be unaware the resident was receiving oxygen therapy. 2. Record review of physician orders dated February 2024 indicated Resident #265, admitted [DATE], was [AGE] years old with a diagnosis of Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems) and dependence on supplemental oxygen (when there is not enough oxygen in your bloodstream to supply tissues and cells, then you need supplemental oxygen to keep your organs and tissues healthy). The orders did not indicate the resident was receiving supplemental oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the admission MDS assessment dated [DATE] indicated Resident #265 was alert and oriented with a BIMS of 14 (indicates no cognitive impairment) and received oxygen therapy on admission and while a resident. Record review of an undated care plan indicated Resident #265 had an altered respiratory status/difficulty breathing related to COPD. One of the interventions was to administer oxygen continuously per physician orders. Record review of physician order dated 02/13/24 (after surveyor intervention) indicated Resident #265 was to receive oxygen at 3 liters per minute (LPM) per nasal cannula (NC) continuously. During an observation and interview on 02/12/24 at 11:22 a.m., Resident #265 was sitting up in her wheelchair in her room. She was receiving oxygen at 3 LPM per NC. She said she received her oxygen continuously and that nursing changed the humidifier bottle and tubing weekly. During an interview on 02/13/24 at 2:32 p.m., LVN D said she was the nurse who admitted Resident #265. She said the resident arrived at the facility by ambulance and was receiving oxygen at the time of admission. She said the resident reported receiving oxygen prior to her hospitalization and during her hospital stay. She said she had left the supplemental oxygen order off the admission orders in error, and it should have been included. She said not having an order for oxygen could result in the resident receiving too much or too little oxygen. 3. Record review of a face sheet dated February 2024 indicated Resident #314, admitted [DATE], was an [AGE] year-old female with diagnoses of dementia and hypertensive heart disease without heart failure. Record review of an Admission/ readmission Evaluation (48 hour Care Plan) indicated Resident #314 received oxygen at 2 liters/ minute by nasal canula chronic. Record review of physician orders dated February 2024 did not indicate Resident #314 received oxygen therapy. During an observation and interview on 02/11/24 at 9:44 a.m. Resident #314 was lying in bed wearing oxygen at 3 liters/minute per nasal canula. Resident #314 said she had only been here 3 days, but her oxygen was monitored by staff. During an interview on 02/13/24 at 11:02 a.m., the DON said Residents #6, #265, and #314 had no physician order for supplemental oxygen. He said the orders were left off in error and there should be an order to indicate LPM ordered and to administer the oxygen by NC. He said he expected orders to be recorded timely and accurately. He said the possible negative outcome of not having a physician order for oxygen was the resident could receive too much or too little oxygen. He said the admission nurse was responsible for entering all admission orders into the system and the Unit Manager was responsible for double checking admission orders for accuracy. During an interview on 02/13/24 at 2:45 p.m., LVN E said she was the nurse who admitted Resident #314. She said the resident arrived at the facility by ambulance and was receiving oxygen at the time of admission. She said she left the supplemental oxygen order off the admission orders in error, and it should have been included. She said not having an order for oxygen could result in the oncoming staff not being unaware the resident received oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 02/13/24 at 4:09 p.m. the administrator said his expectation was for all physician orders including oxygen therapy to be completed accurately and timely. He said the DON was ultimately responsible for physician order accuracy. During an interview on 02/14/24 at 8:15 a.m. the Unit Manager said the admission nurse was responsible for inputting all physician orders including oxygen orders into the computer system. She said she was responsible for double-checking the orders for accuracy. The Unit Manager said the oxygen orders were overlooked for Resident's #6, #265, and #314. She said all the nurses were in-serviced on the importance of inputting all physician orders into the computer. She said the risk of oxygen orders not in the system was staff may not be aware the resident was receiving oxygen therapy. Record review of an Oxygen Administration policy dated 02/13/23 indicated: . Oxygen is administered under orders of a physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observations, interviews, and record reviews, the facility failed to ensure nurse aides were able to demonstrate competency in providing incontinence care necessary to care for 1 of 1 CNAs (CNA B) observed for incontinent care. * CNA B did not change gloves, sanitize/wash hands between glove changes, touched clean items with dirty gloves, and did not completely clean Resident #04 when providing incontinent care. This failure could place residents who required incontinent care at risk for an unsanitary environment, cross contamination, and infection. Findings included: During an observation and interview on 02/12/24 at 09:50 a.m. CNA B provided incontinent care to Resident #04. CNA B donned gloves, opened a bag for trash, and placed it on the foot of the bed. CNA B then grabbed the clean brief and opened it placing it on the bag for trash. CNA B opened the dirty brief, pushed the front down between resident legs, and tucked the sides under the resident. CNA B opened a package of disposable wipes and pulled out 2 wipes. CNA B wiped down the left groin, folded over the wipes, and with clean side of wipes she wiped down the left groin. CNA B pulled out 3 more wipes from the package and wiped from the front down the middle of the resident's peri area. CNA B she rolled the resident to her left side and pulled out more wipes from the package with the same gloves. CNA B took the wipes and wiped the rectal area. The wipes had feces on them. CNA B then without changing gloves pulled clean wipes out of the package and wiped the rectal area again. CNA B did not wipe the right buttock or right hip. CNA B removed the dirty brief under the resident and without changing gloves or performing hand hygiene grabbed the clean brief and placed it under the resident. CNA B then rolled the resident to her right side and pulled out the clean brief. CNA B did not clean the resident left hip or buttock and closed the brief. CNA B rolled the resident to her back, placed the dirty brief into the trash bag and doffed her gloves placing them in the bag, and tied the bag closed. CNA B without sanitizing/washing her hands pulled the resident gown down, covered her with the sheet and blanket, and adjusted the bed. CNA B then washed her hands and exited the room. CNA B said she would not have done anything different with the incontinent care provided to Resident #04. During an interview on 02/14/24 at 10:20 a.m. LVN C said the CNAs should change their gloves between clean and dirty procedures. She said they were to either sanitize or wash their hands between glove changes. She said they were to wash their hands when entering and exiting resident rooms. She said they should not touch clean items with dirty gloves. She said they should pull wipes from the package before they start incontinent care. She said the residents' buttocks and hips should be cleaned because the urine goes everywhere on them in the brief. She said touching clean items with dirty hands/gloves could spread infection. She said residents should be cleaned completely or they could have lingering odors. During an interview on 02/14/24 at 11:45 a.m. the DON said staff were to sanitize hands between glove changes unless there was feces then they should wash their hands. He said staff should change gloves at least between clean and dirty procedures. He said they should not touch clean items with gloves after touching dirty items. He said staff should not pull clean wipes from the package using the soiled gloves. He said when staff cleaned a resident, they should clean both hips and both buttocks. He said cross contamination could spread infection and not cleaning completely could result in skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 0726 issues. Level of Harm - Minimal harm or potential for actual harm An Incontinent Care Policy and Procedure dated 06/15/23 indicated: II. Procedural guidelines: Residents Affected - Few A. Wash hands. Wear gloves and follow standard precautions. D. [NAME] gloves: prior to contacting potentially contaminated items. E. Remove soiled linens/brief: place in bag for disposal. F. Cleanse resident from front to back using a new wipe for each area. G. Cover resident to protect their dignity, remove soiled gloves and sanitize or wash hands. H. Apply new gloves and apply new brief and dry clothing A Hand Hygiene policy dated 06/14/23 indicated: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. .3. Alcohol-based hand rub with 60-95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. b. Gloves: .iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. Residents Affected - Many * The facility did not ensure baking sheets did not have brown and/or black baked on build up and stacked together. * The facility did not ensure the juice dispenser wand did not have cream colored build up inside. * The facility did not ensure a handwashing sink had a trash can for disposable paper towels. * The facility did not ensure skillets did not have brown baked on build up and stacked together. * [NAME] A did not ensure food was at a safe temperature prior to serving food to residents. * The facility did not ensure muffin pans did not have brown baked on build up and stacked together. These failures could place residents who eat from the kitchen at risk of foodborne illnesses. Findings included: During observations and interviews on 02/12/24 during initial tour of the kitchen at 08:46 a.m. indicated: * There were 25 large baking sheets and 1 half baking sheet with dark brown build up inside the corners, the outside edges, and were stacked together; * There was a juice dispenser wand with cream colored buildup in it. The DM said she had tried to take the wand apart and could not get the buildup out of the wand; * The handwashing sink on the dishwasher side of the wall had no trash can near the sink; and * There were 9 multiple sized skillets with dark brown/black buildup outside stacked together. The DM said she had tried different things to get the buildup off of the baking sheets and skillets. During observations and interviews of the lunch meal service on 02/13/24 indicated: * at 11:15 a.m. there was food already on the steam table-a pan of chicken and rice casserole, 2 pans of broccoli florets, 1 pan of chicken and noodles, 1 pan of beef patties, and 1 pan of fish. * at 11:16 a.m. [NAME] A was finishing up the pureed chicken and rice casserole, put it in a small steam pan, and placed the pan on the steam table. * at 11:18 a.m. [NAME] A pureed the broccoli florets. * at 11:22 a.m. [NAME] A put the broccoli florets in a small steam pan and placed the pan on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 steam table. Level of Harm - Minimal harm or potential for actual harm * from 11:25 a.m. to 11:35 a.m. [NAME] A checked the temperatures of the broccoli florets, the chicken and rice casserole, the pureed chicken and rice casserole, and the pureed broccoli florets. [NAME] A did not check the temperatures of the pan of chicken with spiral noodles, the pan of beef patties, or the pan of the fish. Residents Affected - Many * at 11:45 a.m. [NAME] A fixed the first plate with fish tacos using the fish from the pan on the steam table. Surveyor asked [NAME] A what was the temperature of the fish and she responded it was 187 degrees. Surveyor asked when was the temperature checked on the fish and [NAME] _ responded when she pulled it out of the oven before being placed on the steam table. Surveyor asked why she did not check the temperature of the fish when she checked the other foods on the steam table and she said she always checked it only when she pulled it out of the oven. * at 11:46 a.m. Surveyor asked the DM about checking the temperature of the fish and she said they always check the fish when it was pulled out of the oven. Surveyor asked DM how would they know if the fish was at the required holding temperature when it sat on the steam table for an extended time before being served to a resident if they did not check it when they checked the other foods. [NAME] A checked the pan of fish temperature before serving the plate to a resident. Surveyor informed DM the chicken and noodles, beef patties, and fish were not checked for their temperatures before the start of serving the meal. * at 12:00 p.m. the DM acknowledged the muffin pans with dark brown build up on the outside surface and stacked together. She said she had tried to get the buildup off the muffin pans. According to the US Food and Drug Administration Food Code dated January 18, 2023: 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (I) EMPLOYEES are properly maintaining the temperatures of TIME/TEMPERATURE CONTROL FOR SAFETY FOODS during hot and cold holding through daily oversight of the EMPLOYEES' routine monitoring of FOOD temperatures; 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5°C (41°F) or less. .4-6 Cleaning of Equipment and Utensils (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 4-601 Objective Level of Harm - Minimal harm or potential for actual harm 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Residents Affected - Many (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 6-301.20 Disposable Towels, Waste Receptacle. A HANDWASHING SINK or group of adjacent HANDWASHING SINKS that is provided with disposable towels shall be provided with a waste receptacle FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 observations, interviews, and record reviews 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 1 of 1 residents (Resident #04) observed for incontinent care. Residents Affected - Few * CNA B did not change gloves, sanitize/wash hands between glove changes, touched clean items with dirty gloves, and did not completely clean Resident #04 when providing incontinent care. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a face sheet dated 02/14/24 indicated Resident #04 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included urinary incontinence and mixed irritable bowel syndrome. Record review of an MDS assessment dated [DATE] indicated Resident #04 had severely impaired cognition with a BIMS score of 03 (0-7 severely impaired), she was dependent for toileting hygiene, she was dependent for rolling to the left and right side, and she was always incontinent of bladder and bowel. Record review of a care plan dated 12/11/23 for last review indicated Resident #04 had an ADL Self Care Performance Deficit requiring extensive assistance of 1 staff member for toilet use, rolling left and right in bed evaluation at substantial/maximal assistance, toileting hygiene evaluation at dependent, and was incontinent of bladder and bowel. During an observation and interview on 02/12/24 at 09:50 a.m. CNA B provided incontinent care to Resident #04. CNA B donned gloves, opened a bag for trash, and placed it on the foot of the bed. CNA B then grabbed the clean brief and opened it placing it on the bag for trash. CNA B opened the dirty brief, pushed the front down between resident legs, and tucked the sides under the resident. CNA B opened a package of disposable wipes and pulled out 2 wipes. CNA B wiped down the left groin, folded over the wipes, and with clean side of wipes she wiped down the left groin. CNA B pulled out 3 more wipes from the package and wiped from the front down the middle of the resident's peri area. CNA B she rolled the resident to her left side and pulled out more wipes from the package with the same gloves. CNA B took the wipes and wiped the rectal area. The wipes had feces on them. CNA B then without changing gloves pulled clean wipes out of the package and wiped the rectal area again. CNA B did not wipe the right buttock or right hip. CNA B removed the dirty brief under the resident and without changing gloves or performing hand hygiene grabbed the clean brief and placed it under the resident. CNA B then rolled the resident to her right side and pulled out the clean brief. CNA B did not clean the resident left hip or buttock and closed the brief. CNA B rolled the resident to her back, placed the dirty brief into the trash bag and doffed her gloves placing them in the bag, and tied the bag closed. CNA B without sanitizing/washing her hands pulled the resident gown down, covered her with the sheet and blanket, and adjusted the bed. CNA B then washed her hands and exited the room. CNA B said she would not have done anything different with the incontinent care provided to Resident #04. During an interview on 02/14/24 at 10:20 a.m. LVN C said the CNAs should change their gloves between clean and dirty procedures. She said they were to either sanitize or wash their hands between (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 - Few glove changes. She said they were to wash their hands when entering and exiting resident rooms. She said they should not touch clean items with dirty gloves. She said they should pull wipes from the package before they start incontinent care. She said touching clean items with dirty hands/gloves could spread infection. During an interview on 02/14/24 at 11:45 a.m. the DON said staff were to sanitize hands between glove changes unless there was feces then they should wash their hands. He said staff should change gloves at least between clean and dirty procedures. He said they should not touch clean items with gloves after touching dirty items. He said staff should not pull clean wipes from the package using the soiled gloves. He said cross contamination could spread infection. An Incontinent Care Policy and Procedure dated 06/15/23 indicated: II. Procedural guidelines: A. Wash hands. Wear gloves and follow standard precautions. D. [NAME] gloves: prior to contacting potentially contaminated items. E. Remove soiled linens/brief: place in bag for disposal. F. Cleanse resident from front to back using a new wipe for each area. G. Cover resident to protect their dignity, remove soiled gloves and sanitize or wash hands. H. Apply new gloves and apply new brief and dry clothing A Hand Hygiene policy dated 06/14/23 indicated: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. .3. Alcohol-based hand rub with 60-95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. .6. Additional considerations: a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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 The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Level of Harm - Minimal harm or potential for actual harm b. Residents Affected - Few Gloves: .iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 If continuation sheet Page 17 of 17