Health inspection·January 4, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Video link #1- CNA C and LVN D entered Resident #3's room. Resident #3's sheets and covers appeared rumpled and out of place. CNA C covered the camera. Video link #2- CNA C uncovered the camera and Resident #3 was lying in bed and the sheets and bed covers appeared neat and tucked. Residents Affected - Few During an observation on 12/21/23 at 2:42 p.m., Resident #3 was lying in bed sleeping. The camera was directly across from the foot of her bed. The camera was uncovered and appeared to be in working condition. During an interview on 12/21/23 at 12:26 p.m., the DON said she was not aware of any staff barred from providing care to any resident. She said she would have completed a grievance related to resident care if she was made aware. She said all staff can complete grievances. She said she would review the grievances to ensure they were resolved. During an interview on 01/04/23 at 10:00 a.m., the administrator said Resident #3's family member made him aware of CNA C covering up the video camera during care. He said he did not write up a formal grievance. He said Resident #3's family member said she did not want CNA C to provide care to Resident #3. He said he advised the family member CNA C would not provide care to Resident #3. He said the staff were re-trained on 11/27/23 to not cover the camera in Resident #3's room. He said CNA C had not provided care for Resident #3 since he was made aware of the camera being covered up. During an interview on 01/04/23 at 10:23 a.m., LVN D said she went in Resident #3's room to assist with care because sometimes Resident #3 required two persons to provide care. She said she could not recall CNA C covered up the camera in Resident #3's room. She said she was inserviced on 11/27/23 that staff were not to cover any cameras in resident rooms. During an interview on 01/04/23 at 12:24 p.m., ADON E said he was made aware Resident #3's family member complained CNA C covered up the video camera during care. He said CNA C has not provided care to Resident #3 since the incident. He said all staff were retrained on 11/27/23 to not cover up the video cameras during care. He said he did not write up a formal grievance related to the family member's complaint of the CNA C covering up the camera. The surveyor attempted to contact CNA C on 01/04/23 by cell phone and text. CNA C's phone was not accepting calls or texts. Record review of the facility's Grievance policy dated 02/10/17 indicated Residents may voice grievances without interference, coercion, discrimination or reprisal from the facility. Resident rights will be enforced.A prompt investigation and resolution will be made for all grievances residents may have. Grievances include those related to treatment furnished, treatment that has not been furnished and behavior of staff and of other residents, and concerns during their stay. All grievances must be investigated and the report of the grievance may be oral or written, and they can be anonymous.The nursing facility will assign a designated grievance official. The grievance official will:-Oversee the process for reporting, receiving, investigating, tracking, and resolving grievances including written notification of the resolution and outcome to the individual who filed the complaint/grievance. The grievance official of (the facility) is (name) RN DON. The facility's Resident Right's policy dated 01/03/16 indicated . Grievances-You have the right to voice grievances to this facility or other agency concerning your care, treatment, behavior of staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676122 If continuation sheet Page 2 of 9 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 676122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Nursing Home 6230 Warren St Groves, TX 77619 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and/or other residents as well as other concerns about your stay without fear of discrimination or reprisal. You have the right to information on how to file a grievance or complaint. You have the right to prompt resolution of grievances. Record review of the facility's undated Electronic Monitoring Policy indicated (the facility) follows the Texas Health and Human Services guidelines for electronic monitoring . Event ID: Facility ID: 676122 If continuation sheet Page 3 of 9 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 676122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Nursing Home 6230 Warren St Groves, TX 77619 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 8 residents (Resident #s 1 and 2) reviewed for abuse. Residents Affected - Few The facility failed to ensure the abuse coordinator and/or designee implemented the facility policy to report immediately to HHSC within two hours of an allegation or incident of alleged abuse after Resident #2 threatened to choke Resident #1 and punched Resident #1 in the left eye on 12/08/23. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of the facility's undated Reporting Abuse and Neglect Policy indicated Any facility staff member who has cause to believe that the physical or mental health of a resident has been, or may be adversely affect(ed) by abuse, neglect, or exploitation case(ed) by another person, is to report the abuse, neglect or exploitation immediately.3. Will ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Record review of Resident #1's face sheet dated 12/21/23 indicated he was an [AGE] years old male, admitted on [DATE], and his diagnoses included cerebral infarction (stroke), hemiplegia (paralysis affecting one side of the body) following cerebral infarction affecting left non-dominant side, insomnia (sleep disorder), and anxiety (feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated he was able to make himself understood and understood others, he had severe cognitive impairment (BIMS score of 7), and exhibited physical behavior symptoms directed at others. Record review of Resident #1's care plan dated 12/08/23 indicated there was bruise/swelling to eye due to altercation with roommate. Interventions included RP and MD notified of the incident and roommate was moved to another room. Record review of Resident #2's face sheet dated 12/21/23 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included hemiplegia following cerebral infarction affecting right dominant side, emphysema (lung disease that causes breathlessness), pulmonary fibrosis (scarring of the lungs), insomnia, and anxiety. Record review of Resident #2's MDS dated [DATE] indicated he was able to make himself understood and understood others, he had moderate cognitive impairment (BIMS score of 12). He had no exhibited behaviors. Record review of Resident #2's care plan dated 12/08/23 indicated he hit his roommate after his roommate became verbally and physically aggressive toward him. Interventions included he was moved to another room and to monitor and document behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676122 If continuation sheet Page 4 of 9 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 676122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Nursing Home 6230 Warren St Groves, TX 77619 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the incident report dated 12/08/23 at 8:00 p.m. and completed by LVN A indicated Resident #2 hit Resident #1 in the left eye. Resident #1 sustained a bruise to left eye area. The physician and RP were notified. The DON and the Administrator signed and dated the incident report on 12/08/23. Record review of Resident #1's progress note dated 12/08/23 at 9:06 p.m., completed by LVN A indicated Resident #1 was sitting in his bed when Resident #2 (his roommate) got in his face about him changing the TV. Resident #2 walked away. Resident #1 threw a tissue box at Resident #2. Resident #2 I want to choke the shit out of you. Resident #1 put his right hand on Resident #2's chest. Resident #2 punched Resident #1 in his left eye causing a black eye. They were separated and Resident #2 was moved another hall and room. The RP was notified and she came to the facility with video of the incident on her phone. Record review of Resident #2's progress note dated 12/08/23 at 9:34 p.m., completed by LVN A indicated Resident #2 got in a yelling match with Resident #1. Resident #2 grabbed the remote out of Resident #1's hand and started yelling. Resident #1 threw tissue box at Resident #2. Resident #2 returned to Resident #1. Resident #1 put his right hand on Resident #2's chest. Resident #2 punched Resident #1 in the left eye causing a black eye. Resident #2 was then moved to another hall and room. Record review of a grievance dated 12/08/23 indicated Resident #1's RP reported Resident #1 got into a fight with Resident #2 over the remote and Resident #2 hit Resident #1. The DON met with Resident #1's family member and reviewed the video. Resident #1 and Resident #2 were involved in a verbal altercation. Resident #1 put his hand on Resident #2 and Resident #2 reacted. The residents were separated immediate and permanently. Resident #1's family members indicated they were aware Resident #1 participated in the altercation and were satisfied with Resident #2 being moved from the room. The grievance was resolved. The DON signed and dated the grievance form on 12/13/23. The surveyor was unable to review the video during the investigation as it was not available. During an interview on 12/20/23 at 12:16 p.m., the Administrator said the incident was not reported to the state because it was an altercation between two residents. He said there was no history between the resident. He said Resident #2 was immediately moved to another hall and room. He said he was the abuse coordinator and the DOM made him aware of the incident immediately after it occurred on 12/08/23. He said it was discussed and determined it was not a reportable incident. During an interview on 12/20/23 at 12:50 p.m., the DON said LVN A notified her on 12/08/23 immediately of Resident #2 hitting Resident #1 in the left eye. She said the incident was not reported because it was an altercation between two residents. She said they got in a fight about the TV remote. She said Resident #1 threw tissue box and then Resident #2 swung and hit Resident #1 in the left eye. She said Resident #1 sustained a black eye. She said neither resident received treatment and there was no lasting effects. She said Resident #2 was moved to another hall and room immediately. She said she was following the facility policy for abuse prevention and the provider letter dated 2007 and that indicated the incident was not reportable if the residents did not have the capacity to act willfully. She said she was not following the updated provider letter regarding reporting abuse. During an interview on 12/21/23 at 11:00 a.m., LVN A said CNA B came to the nurse station and said Resident #1 and Resident #2 got in a fight on 12/08/23. He said he immediately went to their room. He said he asked Resident #2 what happened. He said Resident #2 indicated Resident #1 kept changing the channels on the TV so he (Resident #2) took the remote. He said he moved Resident #2 to a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676122 If continuation sheet Page 5 of 9 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 676122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Nursing Home 6230 Warren St Groves, TX 77619 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few different hall and room. He said he called Resident #1's RP. He said Resident #1's RP indicated she would come to the facility and bring video. LVN A said he observed the video. He said the video showed Resident #2 walked up to Resident #1 and snatched the TV remote and walked back to his bed. He said Resident #1 throws a tissue box. Resident #2 walks back and says he wanted to choke him and lunged toward Resident #2. He said Resident #1 appeared to flinch and put up his hand to stop Resident #2. Resident #1 was in bed and stayed in bed. Resident #2 hits Resident #1 in the left eye. He said Resident #2 said Resident #1's wife can see it on the video. LVN A said Resident #1 said he was fine and nothing was hurting. He said he notified the doctor and there was no new orders. He said he notified the DON. He said he did not notify the administrator of the incident. He said he was trained on abuse and neglect and reporting. He said he reported to the DON immediately who would report the incident to the Administrator. During an interview on 12/21/23 at 2:28 p.m., Resident #2 said he hit Resident #1 because he was an asshole and would not quit changing the TV channels. He said he asked Resident #1 once to change the channels and he kept changing them. He said he asked him a second time and grabbed the remote and took it. He said he did not threaten to choke Resident #1. He said Resident #1 grabbed him so he punched him in his eye. He said Resident #1's wife could see Resident #1 was an asshole on the video. He said he was glad to be moved to another room. During an observation and interview on 12/21/23 beginning at 2:37 p.m., Resident #2 laid in his bed. His left eye area was bruised and discolored. Resident #2 said Resident #1 hit him in the eye with the remote control. He said he did not know why Resident #2 hit him in the eye. He said Resident #2 was moved to another room. He said he was not scared of Resident #2 or any other residents. During an interview on 01/04/24 at 1:53 p.m., CNA B said she was in the hall outside of Resident #1 and Resident #2's room. She said she heard Resident #2 tell Resident #1 to stop changing the TV channels. She said Resident #1 continued to change the channels. She said as she went to go in the room she heard Resident #2 tell Resident #1 to stop changing the channels again. She said she did not see Resident #2 hit Resident #1. She said she immediately advised LVN A the residents got in a fight and they went to the room. She said she did not hear Resident #2 threaten he was going to choke Resident #1. She said Resident #2 was moved from the room immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676122 If continuation sheet Page 6 of 9 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 676122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Nursing Home 6230 Warren St Groves, TX 77619 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 8 residents (Resident #s 1 and 2) reviewed for abuse. The facility failed to report resident to resident abuse after Resident #2 threatened to choke Resident #1 and punched Resident #1 in the left eye on 12/08/23. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet dated 12/21/23 indicated he was an [AGE] years old male, admitted on [DATE], and his diagnoses included cerebral infarction (stroke), hemiplegia (paralysis affecting one side of the body) following cerebral infarction affecting left non-dominant side, insomnia (sleep disorder), and anxiety (feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated he was able to make himself understood and understood others, he had severe cognitive impairment (BIMS score of 7), and exhibited physical behavior symptoms directed at others. Record review of Resident #1's care plan dated 12/08/23 indicated there was bruise/swelling to eye due to altercation with roommate. Interventions included RP and MD notified of the incident and roommate was moved to another room. Record review of Resident #2's face sheet dated 12/21/23 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included hemiplegia following cerebral infarction affecting right dominant side, emphysema (lung disease that causes breathlessness), pulmonary fibrosis (scarring of the lungs), insomnia, and anxiety. Record review of Resident #2's MDS dated [DATE] indicated he was able to make himself understood and understood others, he had moderate cognitive impairment (BIMS score of 12). He had no exhibited behaviors. Record review of Resident #2's care plan dated 12/08/23 indicated he hit his roommate after his roommate became verbally and physically aggressive toward him. Interventions included he was moved to another room and to monitor and document behaviors. Record review of the incident report dated 12/08/23 at 8:00 p.m. and completed by LVN A indicated Resident #2 hit Resident #1 in the left eye. Resident #1 sustained a bruise to left eye area. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676122 If continuation sheet Page 7 of 9 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 676122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Nursing Home 6230 Warren St Groves, TX 77619 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician and RP were notified. The DON and the Administrator signed and dated the incident report on 12/08/23. Record review of Resident #1's progress note dated 12/08/23 at 9:06 p.m., completed by LVN A indicated Resident #1 was sitting in his bed when Resident #2 (his roommate) got in his face about him changing the TV. Resident #2 walked away. Resident #1 threw a tissue box at Resident #2. Resident #2 I want to choke the shit out of you. Resident #1 put his right hand on Resident #2's chest. Resident #2 punched Resident #1 in his left eye causing a black eye. They were separated and Resident #2 was moved another hall and room. The RP was notified and she came to the facility with video of the incident on her phone. Record review of Resident #2's progress note dated 12/08/23 at 9:34 p.m., completed by LVN A indicated Resident #2 got in a yelling match with Resident #1. Resident #2 grabbed the remote out of Resident #1's hand and started yelling. Resident #1 threw tissue box at Resident #2. Resident #2 returned to Resident #1. Resident #1 put his hand on Resident #2's chest. Resident #2 punched him in the left eye causing a black eye. Resident #2 was then moved to another hall and room. Record review of a grievance dated 12/08/23 indicated Resident #1's RP reported Resident #1 got into a fight with Resident #2 over the remote and Resident #2 hit Resident #1. The DON met with Resident #1's family member and reviewed the video. Resident #1 and Resident #2 were involved in a verbal altercation. Resident #1 put his hand on Resident #2 and Resident #2 reacted. The residents were separated immediate and permanently. Resident #1's family members indicated they were aware Resident #1 participated in the altercation and were satisfied with Resident #2 being moved from the room. The grievance was resolved. The DON signed and dated the grievance form on 12/13/23. During an interview on 12/20/23 at 12:16 p.m., the Administrator said the incident was not reported to the state because it was an altercation between two residents. He said there was no history between the resident. He said Resident #2 was immediately moved to another hall and room. He said he was the abuse coordinator and the DOM made him aware of the incident immediately after it occurred on 12/08/23. He said it was discussed and determined it was not a reportable incident. During an interview on 12/20/23 at 12:50 p.m., the DON said LVN A notified her on 12/08/23 immediately of Resident #2 hitting Resident #1 in the left eye. She said the incident was not reported because it was an altercation between two residents. She said they got in a fight about the TV remote. She said Resident #1 threw tissue box and then Resident #2 swung and hit Resident #1 in the left eye. She said Resident #1 sustained a black eye. She said neither resident received treatment and there was no lasting effects. She said Resident #2 was moved to another hall and room immediately. She said she was following the facility policy for abuse prevention and the provider letter dated 2007 that indicated the incident was not reportable if the residents did not have the capacity to act willfully. She said she was not following the updated provider letter regarding reporting abuse. During an interview on 12/21/23 at 11:00 a.m., LVN A said CNA B came to the nurse station and said Resident #1 and Resident #2 got in a fight on 12/08/23. He said he immediately went to their room. He said he asked Resident #2 what happened. He said Resident #2 indicated Resident #1 kept changing the channels on the TV so he (Resident #2 took the remote. He said he moved Resident #2 to a different hall and room. He said he called Resident #1's RP. He said Resident #1's RP indicated she would come to the facility and bring video. LVN A said he observed the video. He said the video showed Resident #2 walked up to Resident #1 and snatched the TV remote and walked back to his bed. He said Resident #1 throws a tissue box. Resident #2 walks back and says he want to choke him and lunged toward (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676122 If continuation sheet Page 8 of 9 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 676122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Nursing Home 6230 Warren St Groves, TX 77619 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2. He said Resident #1 appeared to flinch and put up his hand to stop Resident #2. Resident #1 was in bed and stayed in bed. Resident #2 hits Resident #1 in the left eye. He said Resident #2 said Resident #1's wife can see it on the video. LVN A said Resident #1 said he was fine and nothing was hurting. He said he notified the doctor and there was no new orders. He said he notified the DON. He said he did not notify the administrator of the incident. He said he was trained on abuse and neglect and reporting. He said he reported to the DON immediately who would report the incident to the Administrator. During an interview on 12/21/23 at 2:28 p.m., Resident #2 said he hit Resident #1 because he was an asshole and would not quit changing the TV channels. He said he asked Resident #1 once to change the channels and he kept changing them. He said he asked him a second time and grabbed the remote and took it. He said he did not threaten to choke Resident #1. He said Resident #1 grabbed him so he punched him in his eye. He said Resident #1's wife could see Resident #1 was an asshole on the video. He said he was glad to be moved to another room. During an observation and interview on 12/21/23 beginning at 2:37 p.m., Resident #2 laid in his bed. His left eye area was bruised and discolored. Resident #2 said Resident #1 hit him in the eye with the remote control. He said he did not know why Resident #2 hit him in the eye. He said Resident #2 was moved to another room. He said he was not scared of Resident #2 or any other residents. During an interview on 01/04/24 at 1:53 p.m., CNA B said she was in the hall outside of Resident #1 and Resident #2's room on 12:08/23. She said she heard Resident #2 tell Resident #1 to stop changing the TV channels. She said Resident #1 continued to change the channels. She said as she went to go in the room she heard Resident #2 tell Resident #1 to stop changing the channels again. She said she did not see Resident #2 hit Resident #1. She said she immediately advised LVN A the residents got in a fight and they went to the room. She said she did not hear Resident #2 threaten he was going to choke Resident #1. She said Resident #2 was moved from the room immediately. Record review of the facility's undated Reporting Abuse and Neglect Policy indicated Any facility staff member who has cause to believe that the physical or mental health of a resident has been, or may be adversely affect(ed) by abuse, neglect, or exploitation case(ed) by another person, is to report the abuse, neglect or exploitation immediately.3. Will ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676122 If continuation sheet Page 9 of 9