Health inspection·November 15, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for the past 3 weeks. She said she was aware of the elopement of Resident #1. She said the DON was terminated and she came in to assist the facility. She said was not aware if the incident had been called in to the state agency. During an interview on 11/4/23 at 1:48 p.m., Human Resource Manager said she' worked at the facility 9 years. She said she was working on the day of Resident #1 elopement. She said she was not aware if the state agency was informed of the elopement. She denied being questioned by the Administrator or the DON concerning the elopement of Resident #1. During an interview on 11/4/23 at 2:20 p.m., the Administrator identified himself as the Administrator and acknowledged he was the abuse coordinator. He said he has worked at the facility for the past 4 months. He said he was made aware of the elopement of Resident #1 on the day of the elopement. The administrator said he did not report the incident to the state agency because he was told Resident #1 was let out of the facility by another resident's family but was immediately re-directed back in the facility. During an interview on 11/15/23 at 11:44 a.m., the Administrator said d the incident was called into the state agency on 11/6/23 and he will call in all any further reports of abuse/neglect to the state agency in the allotted time as required by the state. Record Review of the facility's abuse/neglect policy dated December 2009 stated the following; Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management; A completed copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator. The Administrator will provide a written report of the results of all abuse investigations and appropriate actions taken to the state agency and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676368 If continuation sheet Page 2 of 12 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 676368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treviso Transitional Care 1154 East Hawkins Parkway Longview, TX 75605 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 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure allegations of neglect were thoroughly investigated to prevent further elopement and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #1) of 4 residents reviewed for neglect. Residents Affected - Few The facility failed to immediately investigate, protect the resident, and report allegations of neglect when: Resident #1 eloped from the facility for an unknown amount of time and was found down the street approximately 150 yards from the facility by law enforcement. She had crossed a street and was in a 30 mile per hour area. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 11/4/23 at 7:25 p.m. While the IJ was removed on 11/6/23 at 11:20 a.m., the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could affect residents by placing the residents at risk for harm. Findings include: Record review of a Face Sheet dated 11/4/23 for Resident #1 indicated she admitted to the facility on [DATE] and she is [AGE] years old with diagnoses of chronic obstructive pulmonary disease, cognitive communication deficit, type II diabetes mellitus, unspecified dementia, unspecified psychosis, abnormalities of gait and mobility, and lack of coordination. Record review of a care plan dated 10/4/2023 for Resident #1 indicated she is an elopement risk/wander and needed to be monitored frequently by staff. A Quarterly MDS dated [DATE] indicated Resident #1 has impairment in thinking with a BIMS score of 3. She requires supervision when walking in room and corridor and with locomotion on and off the unit. Record review of Incident Log dated 11/4/23 indicated Resident #1 had an elopement on 10/8/23 at 11:00 a.m. Record review of the In-Service book indicated an Elopement In-service was initiated on 10-18-23. There were a total of 23 names listed on the sign in sheet for this training. Record review of a nurse progress note dated 10/8/23 by nurse A indicated Resident #1 was found outside of the facility and was brought back inside. During an interview on 11/4/23 at 12:53 p.m., CNA B said she's been employed at the facility for 5 months. She said on 10/8/23 she was one of the CNAs caring for Resident #1. She said she last (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676368 If continuation sheet Page 3 of 12 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 676368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treviso Transitional Care 1154 East Hawkins Parkway Longview, TX 75605 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few remember seeing Resident #1 at breakfast. She said she began looking for Resident #1 around 9:30 a.m. She said she had last saw Resident #1 at 9:00 a.m. but had not seen her again. She said she searched halls and rooms but was unable to locate her. She said she notified LVN A she was unable to locate Resident #1 and they both searched for Resident #1. She said after being unable to locate Resident #1 in the facility she went outside and was looking up and down the street. She said she located Resident #1 approximately 200 yards down the street talking to law enforcement. She said when she got to Resident #1, she appeared confused and upset. She said she attempted to get Resident #1 to walk back to the facility with her, but Resident #1 refused. She said a few minutes later LVN A arrived on the scene and attempted to get Resident # 1 to return to the facility. She said Resident #1 said she wanted the police to take her back to the facility. She said law enforcement agreed to follow Resident #1 to the facility. She said LVN A persuaded Resident #1 to get in LVN A car and she transported Resident #1 back to the facility with the police closely following. She said she did not tell the administrator about the incident because she heard LVN A talking to the administrator about the incident. She denied the DON or administrator asked her about the situation. During an interview on 11/4/23 at 12:59 p.m., CNA C said she's been employed at the facility for 2 months. She said she was at work on the day of the elopement of Resident #1. She said she helped search for her in the facility, but she denied going outside to look for Resident #1. She denied anyone questioned her regarding the elopement of Resident #1. She also denied receiving training/in-service on abuse/neglect or elopement. During an interview on 11/4/23 at 1:10 pm., with Corporate Nurse said she's worked in the facility for the past 3 weeks. She said she was aware of the elopement of Resident #1. She said the DON was terminated and she came in to assist the facility. She said she was not sure if an investigation was completed prior to her arrival at the facility nor was she aware if the incident had been called in to the state agency. During an interview on 11/4/23 at 2:20 p.m., the Administrator identified himself as the Administrator and acknowledged he is the abuse coordinator. He said he has worked at the facility for the past 4 months. He said he was made aware of the elopement of Resident #1 on the day of the elopement. The administrator said he did not report the incident to the state agency because he was told Resident #1 was let out of the facility by another resident's family but was immediately re-directed back in the facility. He denied investigating the incident. He said he instructed the DON to investigate. He denied having record of the DON's investigation. The Administrator said the DON did not investigate and was terminated for not being unable to fulfill her job duties. During an interview on 11/4/23 at 3:38 p.m., LVN A said she's worked at the facility 4 years. She said she works the 6 AM - 6 PM and she works every other weekend. She said she was Resident #1 nurse on the day of the incident. She said Resident #1 has a habit of wandering around the facility. She said she was notified by CNA B that Resident #1 was missing but didn't remember the time of day she was notified. She said both she and CNA B searched for Resident #1 inside the facility. She said she notified the Administrator of the resident missing after being unable to locate her inside the facility. She said after searching inside they went outside and began searching. She said she got in her car and began driving down the road. She said was driving up the street when she received a call from the HR Manager. She said the HR Manager told her Resident #1 had been located, and she was the opposite direction in which she was traveling. She said she turned around and headed to where Resident # 1 was located. She said when she arrived Resident #1 was there with CNA B and law enforcement. She said Resident #1 appeared upset and confused when she spoke to her. She said she tried to calm Resident #1 down and coax her to get in the car but Resident #1 refused. She said Resident #1 said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676368 If continuation sheet Page 4 of 12 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 676368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treviso Transitional Care 1154 East Hawkins Parkway Longview, TX 75605 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wanted the police to take her back to the facility. LVN A said law enforcement told Resident #1 they would follow her back to the facility in their car, if she rode with LVN A. She said Resident #1 agreed and got LVN A car. She said she called the Administrator and informed him Resident #1 had been found. She said after they returned to the facility. She did a head-to-toe assessment on Resident #1 and no injuries were found. She said called Resident #1 daughter and nurse practitioner and notified them of the incident. She said she notified the DON and was told to place Resident #1 on one-on-one and to not allow Resident #1 out of her site. She said the DON told her to only document, Resident #1 got out of the facility and was found. LVN A said she only documented what she was told in the chart. LVN A said she was not questioned on the incident by the administrator or the DON. She also denied receiving in-service/training on elopement or abuse/neglect after the incident. During an interview on 11/6/23 at 10:33 a.m., CNA D said she was here on the day of the elopement, but she was working on the other side of the facility. She denied talking to the DON or the administrator about the incident. She also denied the DON or administrator spoke to her about the incident. Record Review of the facility's abuse/neglect policy dated December 2009 stated the following; Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management; A completed copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator. The Administrator will provide a written report of the results of all abuse investigations and appropriate actions taken to the state agency and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. On 11/4/23 at 7:25 p.m., the Administrator was informed an Immediate Jeopardy (IJ) was identified due to the above failure. The IJ template was provided to the Administrator and a Plan of Removal (POR) was requested. The plan of removal indicated the following: Residents residing in the facility have the potential to be affected by the failure to investigate allegations of neglect. Resident #1 was placed on one-on-one supervision. Resident will be removed from one-on-one and placed on Q15 checks after evaluation from NP. Resident will be removed from Q15 with no episode of elopement for 72 hours. MD was notified, resident was treated for UTI 10/9 to help with confusion. Residents care plan updated to address elopement risk. Speaking with Physician on 11/6 monthly CBC ordered to monitor white blood cell count to help identify and treat potential confusion. The facility initiated an investigation to identify the cause and implement interventions. All residents residing in the facility have the potential to be affected by this deficiency. An audit was completed to ensure other residents with the potential for elopement were given the same interventions. One other resident was identified for elopement risk were place on 15min q checks. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676368 If continuation sheet Page 5 of 12 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 676368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treviso Transitional Care 1154 East Hawkins Parkway Longview, TX 75605 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 0610 The following actions were initiated immediately on 11/4/23. Level of Harm - Immediate jeopardy to resident health or safety A. Residents Affected - Few On 11/4/23 an in-service was initiated with the Administrator/DON by the RVP on the need to report and thoroughly investigate allegations of abuse and neglect to include allegations of elopement to ensure proper interventions are placed for residents' safety. The incident will be reported to HHSC. B. On 11/4/23 an in-service was initiated by the Administrator with All facility staff on the need to report allegations of abuse and neglect including allegations of elopement to the abuse coordinator to ensure proper interventions are placed for residents' safety. Staff will not be allowed to work on the floor without receiving the in-service completion date for training will be 11.5.23 C. An audit was completed on 11/4/23 by the Administrator of the 72-hour summary Report and grievances for all residents residing in the facility for any reported neglect allegations, none were identified. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 11/4/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Plan of Removal was accepted on 11/6/23 at 11:20 a.m. On 11/7/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations were performed on 11/7/23 2:10 p.m. to 6:18 p.m. Resident #1 was observed with staff always with her during the visit. Interviews with 3 Licensed Nurses (on all shifts 6 a.m.- 6 p.m., 6 p.m.-6 a.m.), 1 RN (6 a.m.- 2 p.m.,10 p.m.6 a.m., 6 p.m.- 6 a.m.) and 6 CNAs ( 2 p.m.-10- p.m., PRN) were performed on 11/6/23. All staff were able to correctly identify the abuse coordinator. They stated they had received in-services on abuse/neglect, elopement, and who and when to report abuse/neglect allegations. The staff stated they learned to report missing residents over the intercom system immediately, and to notify the charge nurse and abuse coordinator/administrator. During an interview on 11/15/23 at 11:44 a.m., the Administrator said staff were in-serviced on abuse/neglect, and elopement. The Administrator said staff not in-serviced will be in-serviced prior to their shift. The Administrator said he and the cooperate nurse are monitoring the staffing schedule to ensure all staff on the schedule have been trained or still need to be. The Administrator said the employee files were reviewed and updated with the required trainings and files will be audited bi-weekly for 1 month, monthly for 3 months and then quarterly to ensure all employees have completed the required trainings. The Administrator said employee file audits will be discussed monthly during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676368 If continuation sheet Page 6 of 12 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 676368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treviso Transitional Care 1154 East Hawkins Parkway Longview, TX 75605 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the monthly Quality Assurance meeting or as needed. The Administrator said staff will be in-serviced upon hire and annually. He said Resident #1 was being moved on 11/17/23 to a different facility where her needs could be met. The Administrator said the incident was called into the state agency and he will call in all any further reports of abuse/neglect to the state agency in the allotted time as required by the state. On 11/7/23 at 5:36 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not an Immediate Threat and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems. Event ID: Facility ID: 676368 If continuation sheet Page 7 of 12 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 676368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treviso Transitional Care 1154 East Hawkins Parkway Longview, TX 75605 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to provide adequate supervision to prevent elopement for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, and supervision in that: Residents Affected - Few Resident #1 eloped from the facility for an unknown amount of time and was found approximately 150 yards away from the facility by a neighboring facility and law enforcement. She had crossed a street and was in a 30 mile per hour area. An Immediate Jeopardy (IJ) was identified on 11/4/23 at 7:25 p.m. While the IJ was removed on 11/6/23 at 11:20 a.m., the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could affect residents by placing the residents at risk for harm. Finding include: Record review of a Face Sheet dated 11/4/23 for Resident #1 indicated she admitted to the facility on [DATE] and she was [AGE] years old with diagnoses of chronic obstructive pulmonary disease, cognitive communication deficit, type II diabetes mellitus, unspecified dementia, unspecified psychosis, abnormalities of gait and mobility, and lack of coordination. A Quarterly MDS dated [DATE] indicated Resident #1 had impairment thinking with a BIMS score of 3. She required supervision when walking in room and corridor and with locomotion on and off the unit. Record review of a care plan dated 10/4/2023 for Resident #1 indicated he was an elopement risk/wander and needed to be monitored frequently by staff. Record review of a nurse progress note dated 10/8/23 by nurse A indicated Resident #1 was found outside of the facility and was brought back inside. Record review of Incident Log dated 11/4/23 indicated Resident #1 had an elopement on 10/8/23 at 11:00 a.m. Record review of the In-Service book indicated an Elopement In-service was initiated on 10-18-23. During an observation on 11/4/23 at 11:47 a.m. with Resident #1 was found seated in the activities room with another resident. The assistant activities director was seated in her office with the door open. During an interview on 11/4/23 at 12:53 p.m., CNA B said she's been employed at the facility for 5 months. She said on 10/8/23 she began looking for Resident #1 around 9:30 a.m. She said she had last saw Resident #1 at 9:00 a.m. but had not seen her again. She said she searched halls and rooms but was unable to locate her. She said she notified LVN A, and they both searched for Resident #1. She said after being unable to locate Resident #1 in the facility she went outside and was looking up and down the street. She said she located Resident #1 approximately 200 yards down the street talking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676368 If continuation sheet Page 8 of 12 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 676368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treviso Transitional Care 1154 East Hawkins Parkway Longview, TX 75605 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 0689 Level of Harm - Immediate jeopardy to resident health or safety to law enforcement. She said she got to Resident #1 she appeared confused and upset. She said she attempted to get Resident #1 to walk back to the facility with her, but Resident #1 refused. She said a few minutes later LVN A arrived on the scene and attempted to get Resident # 1 to return to the facility. She said Resident #1 said she wanted the police to take her back to the facility. She said law enforcement agreed to follow Resident #1 to the facility. She said LVN A persuaded Resident #1 to get in LVN A car and she transported Resident #1 back to the facility with the police closely following. Residents Affected - Few During an interview on 11/4/23 at 1:48 p.m., Human Resource Manager said she worked at the facility 9 years. She said she was working on the day of Resident #1s elopement. She said LVN A was looking for Resident #1 when she received a call from the facility across the street. She said the person on the phone told her a Resident #1 was located down the street and they believed she was from this facility. She said she notified LVN A. She said when Resident #1 was brought back to the facility she appeared upset and confused. During an interview on 11/4/23 at 2:20 p.m., the Administrator identified himself as the Administrator and acknowledged he was the abuse coordinator. He said he has worked at the facility for the past 4 months. He said he was made aware of the elopement of Resident #1 on the day of the elopement. He said LVN A called him and told him Resident #1 was missing but was found shortly after staff began looking for her. He said he called and notified the DON of the elopement. He denied coming to the facility on the day of the incident. He said he was notified of the elopement after the resident had returned to the facility. The administrator said he did not report the incident because he was told Resident #1 was let out of the facility by another resident's family but was immediately re-directed back in the facility. He said he was not aware of the length of time Resident #1 was outside the facility. He said he was made aware of law enforcement involvement until 10/19/23. He said the DON initiated 15-minute checks on Resident #1. He denied investigating the incident. He said he instructed the DON to investigate. During an interview on 11/4/23 at 3:38 p.m., LVN A said she's worked at the facility 4 years. She said she worked the 6 AM - 6 PM and she works every other weekend. She said she was Resident #1s nurse. She said Resident #1 has a habit of wandering around the facility. She said she was notified by CNA B that Resident #1 was missing but did not remember the time of day she was notified. She said both she and CNA B searched for Resident #1 inside the facility. She said she notified the Administrator of the resident missing after being unable to locate her inside the facility. She said after searching inside they went outside and began searching. She said she got in her car and began driving down the road. She said was driving up the street when she received a call from the HR Manager. She said the HR Manager told her Resident #1 had been located in the opposite direction in which she was traveling. She said she turned around and headed to where Resident # 1 was located. She said when she arrived Resident #1 was there with CNA B and law enforcement. She said Resident #1 appeared upset and confused when she spoke to her. She said she tried to calm Resident #1 down and coax her to get in the car but Resident #1 refused. She said Resident #1 said she wanted the police to take her back to the facility. LVN A said law enforcement told Resident #1 they would follow her back to the facility in their car, if she rode with LVN A. She said Resident #1 agreed and got LVN A car. She said she called the Administrator and informed him Resident #1 had been found. She said after they returned to the facility. She did a head-to-toe assessment on Resident #1 and no injuries were found. She said called Resident #1 daughter and nurse practitioner and notified them of the incident. She said she notified the DON and was told to place Resident #1 on one-on-one and to not allow Resident #1 out of her site. She said the DON told her to only document, Resident #1 got out of the facility and was found. LVN A said she only documented what she was told in the chart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676368 If continuation sheet Page 9 of 12 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 676368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treviso Transitional Care 1154 East Hawkins Parkway Longview, TX 75605 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 0689 Level of Harm - Immediate jeopardy to resident health or safety During an interview on 11/4/23 at 3:55 p.m., the Administrator said the facility set up 15- minute checks on Resident #1 for 3 days following the incident. He said the Nurse Practitioner ordered a urinalysis completed on Resident #1. He said Resident #1 was found to have a urinary tract infection and she was treated per the nurse practitioner's orders . The administrator said for safety precautions, a sign was placed on the door stating, Do not allow anyone outside of the facility except yourself. He said the DON was terminated by the facility on 10/16/23 for not being able to fulfill her job duties. Residents Affected - Few Record Review of the facility's abuse/neglect policy dated December 2009 stated the following; Policy Statement: It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incidents or suspected incidents of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management; Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. On 11/4/23 at 7:25 p.m., the Administrator was informed an Immediate Jeopardy (IJ) was identified due to the above failure. The IJ template was provided to the Administrator and a Plan of Removal (POR) was requested. The plan of removal indicated the following: Residents residing in the facility have the potential to be affected by the failure to provide adequate supervision to prevent elopement. Resident #1 was placed on one-on-one supervision. Resident will be removed from one-on-one and placed on Q15 checks after evaluation from NP. MD was notified, resident was treated for UTI 10/9 to help with confusion. Residents care plan updated to address elopement risk. Speaking with Physician on 11/6 monthly CBC ordered to monitor white blood cell count to help identify and treat potential confusion. The facility initiated an investigation to identify the cause and implement interventions. All residents residing in the facility have the potential to be affected by this deficiency. An audit was completed to ensure other residents with the potential for elopement were given the same interventions. One other resident was identified for elopement risk and placed on Q15 checks, based on evaluation Q15 checks are adequate to meet the patient's needs. 1. The following actions were initiated immediately on 11/4/23. a. One other resident identified for elopement risk, placed on Q15 min checks to be conducted by the nurses. The checks will be documented on the Q 15 form. Nurses in-serviced on _11/15 _ by the DON. The NP will evaluate the patient 11/7 to /determine if q15 is to be removed. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676368 If continuation sheet Page 10 of 12 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 676368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treviso Transitional Care 1154 East Hawkins Parkway Longview, TX 75605 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 0689 Level of Harm - Immediate jeopardy to resident health or safety On 11/4/23 an in-service was initiated with the Director of Nursing and Administrator by the Regional Nurse on the need to identify residents who are at risk for harm because of unsafe wandering to ensure adequate supervision is provided. If a resident is identified at risk for unsafe wandering a staff member will be placed with resident, physician will be notified, and DON and administrator will be notified to adjust staffing schedules. Residents Affected - Few c. On 11/4/23 an in-service was initiated for the licensed nursing staff by the DON/ Designee on the need to identify residents who are at risk for harm because of unsafe wandering to ensure adequate supervision is implemented. All untrained Nursing staff (Nurses, CNA, CMA) will not be allowed to work on the floor without receiving the in-service. This will be completed by 11/5/23 midnight. d. An audit was completed on 11/4/23 on wander-risk residents to determine adequate supervision. One other resident was identified at risk and placed on Q15 minute checks residents care plan updated for elopement risk. MD ordered UA pending results. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 11/4/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Plan of Removal was accepted on 11/6/23 at 11:20 a.m. On 11/7/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations were performed on 11/7/23 2:10 p.m. to 6:18 p.m. Resident #1 was observed with staff always with her during the visit. Interviews with 3 Licensed Nurses (on all shifts 6 a.m.- 6 p.m., 6 p.m.-6 a.m.), 1 RN (6 a.m.- 2 p.m.,10 p.m.6 a.m., 6 p.m.- 6 a.m.) and 6 CNAs ( 2 p.m.-10- p.m., PRN) were performed on 11/6/23. All staff were able to correctly identify the abuse coordinator. They stated they had received in-services on abuse/neglect, elopement, and who and when to report abuse/neglect allegations. The staff stated they learned to report missing residents over the intercom system immediately, and to notify the charge nurse and abuse coordinator/administrator. During an interview on 11/15/23 at 11:44 a.m., the Administrator said staff were in-serviced on abuse/neglect, and elopement. The Administrator said staff not in-serviced will be in-serviced prior to their shift. The Administrator said he and the cooperate nurse are monitoring the staffing schedule to ensure all staff on the schedule have been trained or still need to be. The Administrator said the employee files were reviewed and updated with the required trainings and files will be audited bi-weekly for 1 month, monthly for 3 months and then quarterly to ensure all employees have completed the required trainings. The Administrator said employee file audits will be discussed monthly during the monthly Quality Assurance meeting or as needed. The Administrator said staff will be in-serviced upon hire and annually. He said Resident #1 is being moved on 11/17/23 to a different facility where her needs could be met. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676368 If continuation sheet Page 11 of 12 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 676368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treviso Transitional Care 1154 East Hawkins Parkway Longview, TX 75605 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 0689 Level of Harm - Immediate jeopardy to resident health or safety On 11/7/23 at 5:36 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not an Immediate Threat and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676368 If continuation sheet Page 12 of 12