Health inspection·September 9, 2025

F 0610 Respond appropriately to all alleged violations. 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 all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 2 residents (Resident #1) reviewed for abuse. The facility failed to thoroughly investigate an allegation of abuse reported to the Administrator regarding Resident #1 on 08/25/25. The Administrator did not interview Resident #1, her representative, or the caregiver that verbalized the allegation of abuse. These failures could place residents at risk for abuse, neglect, exploitation, mistreatment, and injuries of unknown source.Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female, admitted to the facility on [DATE], and discharged on 08/25/25. Her diagnoses included dementia (a general term for a decline in mental ability that affects memory, thinking, and social skills to the point of interfering with daily life). Record review of the facility's Provider Investigation Report, dated 09/02/25, reflected: .Resident Profile[Resident #1] is a [AGE] year-old female who was admitted to the skilled unit on August 21, 2025. She has a BIMS of 10 [Moderately Impaired Cognition]. She has impaired cognition function/dementia or impaired thought processes.[Resident #1] has a deficit in self-care activities of daily living., as well as communication difficulties.Additionally she has a sitter to be with her.Description of the Allegation:On August 25, 2025, [Resident #1] was discharged from the facility at the request of her family. On the day of discharge, EMS was on-site to assist with [Resident #1's] transportation home. during this time, Resident #1's sitter was overheard telling EMS personnel that [Resident #1] had been abused and that hospice staff were aware.Provider Response:Upon receiving the verbal allegation of abuse on August 25, 2025, the facility immediately followed internal reporting protocols. The allegation was promptly communicated to the Charge Nurse.and escalated to the Administrator.However, no further protective actions or assessment were taken by the facility because the resident's family elected to discharge [Resident #1] from the facility.The facility conducted staff re-education focusing on Abuse and Neglect. The following individuals were also notified:* DON Notification* ADON Notification*[Corporate [NAME] President] Notification*MD/NP Notification*HHSC Notification.Investigation Summary:.Allegations of Abuse (August 25,2025):At approximately 6:45PM, CNA overheard the sitter telling EMS that [Resident #1] had been abused and that hospice staff were aware. The incident was reported to the charge nurse and administrator.Conclusion:The internal investigation into the abuse allegation revealed no witnesses or identified perpetrators. As a result, the facility concluded that the findings of the investigation were unconfirmed. No further incidents were reported following the resident's discharge.Provider action taken Post-Investigation:Continue staff education on facility policies to prevent and protect residents from all forms of Abuse and Neglect. During an interview on 09/09/25 at 9:54AM, the DON said she was the nurse who assessed the resident for discharge. She said she was not informed of any abuse allegation during her assessment. She said the resident and family were happy with everything that was done leading up to the discharge. She said the Administrator Residents Affected - Few Page 1 of 2 455684 455684 09/09/2025 Longview Hill Nursing and Rehabilitation Center 3201 N Fourth St Longview, TX 75605

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few conducted the investigation into this incident. During an interview on 09/09/25 at 9:58AM, the Administrator said that on the evening of 08/25/25, he received a phone call reporting that a CNA had overheard Resident #1's sitter saying the resident had been abused in the facility. He said the resident had already left the building when he received the call. He said he did not investigate the allegation further because the resident had already left the building. He said he was unsure whether he had contact information for the sitter. He said he had been in Resident #1's room prior to discharge and no one had brought any concerns of abuse to his attention. He said Resident #1's family member was happy with Resident #1's care when he spoke with her prior to the abuse allegation. He said he did not speak with the family member about this allegation of abuse. He said he interviewed the CNA that overheard the conversation. He said he conducted safe surveys with the residents. During an interview on 09/09/25 at 10:26AM, ADON A said she was not present at the facility at the time of the abuse allegation involving Resident #1 on 08/25/25. She said she felt the Administrator should have talked to the family or the sitter regarding the abuse allegation to obtain more information. She said the risk was that abuse could be going on in the facility. During an interview on 09/09/25 at 10:31AM, the DON said she conducted a discharge assessment of Resident #1 and that neither the family nor the sitter reported any allegations of abuse. She said she did not feel like the caregiver should have been called because the family member and caregiver were together at the time of discharge. She said she had a conversation with the sitter on the day of discharge and she did not make an allegation of abuse to her. She said she tried to call the family member one time after the allegation of abuse and she did not answer. She said she felt like she should have attempted to call the family more than once. She said the risk was it was possible there could be abuse going on in the facility. During an interview on 09/09/25 at 10:46AM, the Administrator said the DON attempted to call Resident #1's family member, but no one tried to call the caregiver. He said no one had made any indication to the Administrator or the DON that there were any abuse concerns. He said he did not think someone should have called the family member after the abuse allegation came out because they had spent time with the family and no allegation of abuse had been reported to them. He said he felt that they followed the policy because the DON attempted to contact the family member who was responsible for her care. He said he felt this issue was resolved because the family left with the resident under a safe discharge plan. He said the family and the caregiver did not indicate to them that there were any concerns or abuse allegations. Record review of the facility's policy, Abuse, Neglect and Exploitation, reflected: .It is the policy of this facility to provide protections for the health, welfare and implementing written policies and procedures that prohibit and prevent misappropriation of resident property.V. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation. 455684 Page 2 of 2