Health inspection·July 22, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few reported he got up from his table without his walker and touched Resident #2's wheelchair handle and Resident #2 stated keep your hands off my fucking chair, next time imma kill you then Resident #2 punched Resident #1 with a closed fist and hit Resident #1 with an opened hand to Resident #1's left upper arm. Resident #1 stated that arm had already bothered him and Resident #2 made it worse. LVN A performed a skin assessment and noted redness and handprint to left upper arm of Resident #1 and the area was tender to touch. Resident was provided with PRN pain medication. Review of a psychiatric progress note for Resident #1 for telecommunication visit dated 07/13/2025 reflected Resident #1 discussed two incidents that involved being hit by Resident #2 and since the incident Resident #1 reported feeling unsafe, anxious and hypervigilant around Resident #2. Resident #1 also reported difficulty sleeping and feeling shaky. Resident #1 expressed sadness and emotional distress about his lack of safety in the environment. Review of Resident #1's progress notes reflected no follow up by facility staff (social worker, DON, ADM) were documented after incidents with Resident #2. During an interview on 07/21/2025 at 10:17 AM, Resident #1 stated that he had two incidents with Resident #2. Resident #1 stated that he was in the dining room and tried to get by Resident #2's chair and put his hands on the handle of Resident #2's chair and that Resident #2 stated get your fucking hands of my chair and then Resident #2 hit him on the shoulder and arm. Resident #1 stated the previous day Resident #2 hit Resident #1 on the leg. Resident #1 stated AD was present the first day that Resident #2 hit Resident #1 on the leg. Resident #1 stated he felt Resident #2 knew Resident #1 had a bum shoulder. During a subsequent interview on 07/21/2025 at 10:59 AM, Resident #1 stated that he felt safe when Resident #2 was not around. Resident #1 stated he now preferred to eat his meals in his room because Resident #2 ate in the dining room. Resident #1 stated he felt Resident #2 could easily beat him up. Resident #1 stated that on Saturday (07/12/2025) Resident #2 watched television previews and was not watching any shows and Resident #1 asked Resident #2 what he wanted to watch and Resident #2 stated to Resident #1 fuck you I'm watching this and hit him on the leg. During an interview on 07/21/2025 at 2:51 PM, Resident #1 stated that he was scared of Resident #2 and that he wanted Resident #2 to quit being a bully. Resident #1 stated if he saw Resident #2 in the dining room he would leave and go back to his (Resident #1's) room. Resident #1 stated he would leave the area if he saw Resident #2 show up. Resident #1 stated he was afraid Resident #2 was going to hit him again. Review of Resident #2's face sheet dated 07/21/2025 reflected a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified diastolic (congestive) heart failure (condition where the heart cannot function properly), chronic respiratory failure (condition when the lungs cannot adequately exchange oxygen and carbon dioxide over a long period), acute kidney failure (sudden rapid decrease in kidney function), schizophrenia (chronic mental disorder that disrupts a person's ability to thinking clearly and manage emotions) and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities that interfere with daily life). Review of Resident #2's significant change MDS dated [DATE] reflected a BIMS score of 8 which indicated a moderate cognitive impairment. Further review reflected Resident #2 did not exhibit any physical or verbal behavioral symptoms directed at others in the 7 days prior to the assessment. Review of Resident #2's care plan dated 07/17/2025 reflected Resident had episodes of verbal aggression and hitting with interventions to anticipate behaviors and redirect when in close proximity to others that might invoke aggression, ensure staff is aware of behaviors and increase in behaviors noted. Further review of care plan dated 05/29/2025 reflected Resident #2 had a risk for harm directed at self or others. Goals included no harm to self or others and residents would be free of physically aggressive behaviors and verbally aggressive behavior. Interventions included to minimize environmental stimuli and monitor for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676292 If continuation sheet Page 2 of 7 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 676292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Luling 501 W Austin St Luling, TX 78648 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 0600 Level of Harm - Actual harm Residents Affected - Few signs or symptoms of agitation, and utilize diversion techniques. Review of Resident #2's psychiatric progress note dated 07/09/2025 reflected reason for follow up was for insomnia and behavior issues. Further review reflected Resident #2 had difficulty falling asleep and mood disturbance. Review reflected staff reported mood issue that include aggression and anger outbursts. Review of a progress note by ADON for Resident #2 dated 07/12/2025 reflected that she heard raised voices in the dining are and AD stated that Resident #2 hit Resident #1. ADON observed Resident #2 yell and cuss at AD and Resident #1. Resident #2 stated that mother fucker changed the channel and I hit him. I will beat his ass if he does it again or looks at me. Resident #2 was escorted from the dining area and a visual was kept on him. Review of the incident report dated 07/12/2025 by ADON, reflected ADON heard Resident #2 yell and curse at AD and Resident #1 and Resident #2 stated I will beat his ass if he does it again or looks at me. ADON escorted Resident #2 out of dining area to calm down and kept visual on him and notified ADM, DON, MD and psychiatric provider. Review of a progress note for Resident #1 by LVN A dated 07/13/2025 reflected Resident #1 notified LVN A that Resident #2 hit Resident #1 because he touched Resident #2's wheelchair. Resident #2 denied hitting Resident #1 for touching his wheelchair. Police were notified and while Resident #2 waited to speak to the police he stated I don't care if the policy are here, I'll still beat your ass. Resident was placed on 1:1. Review of the incident reported dated 07/13/2025 by LVN A reflected Resident #1 informed her that Resident #2 hit him. Residents were separated and Resident #2 removed from dining area. Resident #2 refused vitals and admitting to hitting Resident #1 due to Resident #1 touching his wheelchair. LVN A notified ADM, MD and psychiatric provider. Review of a progress note dated for Resident #2 07/14/2025 reflected Resident #2 remained on 1:1. No information regarding Resident #2's behaviors or lack of were documented. Further review of progress notes for Resident #2 reflected no ongoing information regarding Resident #2's 1:1 supervision and whether Resident #2 had any behaviors or no behaviors while on 1:1 supervision. Review of a psychiatric progress note for Resident #2 for telecommunication visit dated 07/15/2025 reflected Resident #2 was referred due to recent behavior that involved physical aggression. Review reflected the incident was triggered by another resident changing the television and this occurred after another confrontation in which the residents argued about tea. Staff reported increasing irritability, poor frustration tolerance and escalating verbal hostility in the days leading up to these events. Review of a psychiatric progress note for Resident #2 dated 07/16/2025 reflected Resident #2 was seen due to behavior disturbance and was placed on one-on-one due to escalation with another resident. Resident #2 reported severe anger outburst with no triggers. Resident denied any want to harm himself or harm to others at the time of the visit. Staff reported Resident #2 had mood issue with aggression and anger outburst. Note reflected Resident #2 was not in acute danger to self or others however condition may change related to worsening medical condition and psychosocial stressors. Note indicated Resident #2 should be monitored closely for any acute/sudden change in mood behavior, and interaction. Review of Resident #2 physician orders reflected behavior monitoring order with a start date of 07/21/2025 to document in progress note every shift any interventions related to antipsychotic behavior that included danger to self or danger to others and striking out/hitting. During an interview on 07/21/2025 at 10:31 AM, Resident #2 stated that he got along with other residents so-so. Resident #2 stated he got into it with Resident #1. Resident #2 stated he sat in the dining room watching television and Resident #1 changed the channel and that made him mad so he hit Resident #1. Resident #2 said he intentionally hit Resident #1 . Resident #2 stated this was the only time he hit Resident #1 and denied hitting him any other times. During an interview on 07/21/2025 at 12:58 PM, the AD stated that on Saturday (07/12/2025) she was on her way out and heard Resident #2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676292 If continuation sheet Page 3 of 7 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 676292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Luling 501 W Austin St Luling, TX 78648 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 0600 Level of Harm - Actual harm Residents Affected - Few curse at Resident #1 and she asked Resident #2 to stop cussing. The AD stated Resident #2 continued to curse and made a fist at her. The AD stated that Resident #2 then hit Resident #1 with an open hand on the leg and arm. The AD stated this happened around noon. The AD stated that Resident #2 cursed at her and ADON then came out and removed Resident #2. The AD stated that she stayed with Resident #1. The AD stated that when residents got into an altercation first thing was to remove the residents from the situation and try to help the residents calm down. The AD stated that she has never observed Resident #2 become physically aggressive and this was a new behavior for him. The AD stated that she received an in-service and information was reviewed to intervene if something happened and how to de escalate the issue and to report immediately to the ADM. The AD stated that an example of physical abuse was hitting or touching a resident. The AD stated she left after she checked on Resident #1. During an interview on 07/21/2025 at 1:08 PM, the ADON stated that on 07/12/2025 around 11:15 AM she heard a raised voice say I'm going to kick your ass and saw the AD with Resident #1 and Resident #2 in the dining room by the television. The ADON stated she approached the area and saw Resident #2 swing at Resident #1. The ADON removed Resident #1 from Resident #2 and assessed Resident #1 for injuries. The ADON stated after she removed Resident #1, Resident #2 still cursed in the dining area. The ADON stated that Resident #2 went outside and was cursing while he left the building and cursed at staff. The ADON stated it took about 10 minutes for Resident #2 to calm down. The ADON stated she called the DON, MD and psychiatric NP. The ADON stated that Resident #2 told her Resident #1 changed the channel and he just did not like Resident #1 . The ADON stated she reported the incident to the ADM and was instructed to keep Resident #1 and Resident #2 separate. The ADON stated that Resident #1 was closely monitored and that Resident #1 and Resident #2 were separated as interventions to the incident. The ADON stated all staff were informed to keep the residents separated. The ADON stated that she did not think she put the incident on the 24-hour report and verbally passed it on to oncoming staff. The ADON stated she did not work on 07/13/2025 and she received a call from LVN A on 07/13/2025 at 11:17 AM that Resident #2 hit Resident #1. The ADON stated she called DON and was instructed to place Resident #2 on 1:1 supervision. The ADON stated she notified LVN A to place Resident #1 on 1:1 supervision. ADON stated she notified the MD, and psych services. ADON stated that she believed Resident #1 was on 1:1 supervision until 07/17/2025 or 07/18/2025. The ADON stated an example of physical abuse was causing harm or hitting someone. The ADON stated that additional staff were brought in to help with 1:1 and that the 1:1 was not documented because staff switched who was assigned throughout the shift. During an interview on 07/21/2025 at 1:40 PM, LVN A stated that Resident #1 reported to her that he was on his way to the kitchen door and touched Resident #2's wheelchair to keep his balance and when Resident #1 touched Resident #2's wheelchair he threatened and cussed at him not to touch his wheelchair and Resident #2 hit Resident #1. LVN A stated that during her assessment of Resident #1, she observed a red mark in the shape of a hand print on his arm. LVN A stated she administered PRN pain medication to Resident #1. LVN A stated that neither resident wanted to leave the dining room so she gathered CNAs and they stood in the dining room. LVN A stated that she called the ADON and ADM and the police. LVNA A stated she received instruction to keep the residents separated. LVN A stated Resident #2 sat in front of the nurses station and watched Resident #1 speak with police and as Resident #1 walked back to his room Resident #2 told Resident #1 I don't care if police offices are here I'll kill you. LVN A stated this occurred right before noon. LVN A stated that Resident #2 was placed on 1:1 supervision. LVN A stated that 15 minutes checks were implemented for Resident #2 as well and the CNA who sat with him filled out a form and LVN A assumed it was turned into the DON. LVN A stated she believed she wrote 1:1 supervision for Resident #2 on the 24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676292 If continuation sheet Page 4 of 7 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 676292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Luling 501 W Austin St Luling, TX 78648 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 0600 Level of Harm - Actual harm Residents Affected - Few hour report and gave report to the oncoming nurse. LVN A stated that when she arrived for her shift on 07/13/2025 she was not aware than an incident occurred with Resident #1 and Resident #2 previously and stated that there were no supervision guidelines for either resident that she was made aware of. LVN A stated an example of physical abuse was putting hands on another resident. During an interview on 07/21/2025 at 2:15 PM, the DON stated that she was notified of the first incident between Resident #1 and Resident #2 that Resident #2 hit resident #1 regarding a television show and that residents were in the dining room. The DON stated that the nurse reached out to her and notified her of the incident. The DON stated she believed interventions for the first incident was that Resident #2 was put on 1:1 supervision but was not sure if that happened during the first or second incident. The DON stated that for the second incident with Resident #1 and Resident #2 she was informed that Resident #1 tried to get to his (Resident #1)'s place in the dining room and he used furniture instead of his walker and touched Resident #2's wheelchair. The DON stated that Resident #2 hit Resident #1 because Resident #1 had touched Resident #2's wheelchair. The DON stated she was not aware of any injuries from the incident. The DON stated she followed up regarding how the residents were doing and spoke with Resident #1 and Resident #2 face to face. The DON stated she saw the note indicated red mark on Resident #1's arm but had no seen any ongoing bruising. The DON stated Resident #2 was put on 1:1 supervision and that 1:1 supervision meant that Resident #2 could be seen at all times. The DON stated that the staff rotated hours for 1:1 and that the ADON set the 1:1 up. The DON stated if Resident #2 did have behaviors it would be documented in the progress notes. The DON stated that she was not sure how documentation looked for 1:1 supervision for Resident #2 but knew staff would switch every hour and would defer to ADON as to when Resident #2 came off 1:1 supervision. The DON stated residents were protected from further abuse or neglect by evaluations, completing BIMS assessments on admission and every quarter and behaviors (if any) being discussed with the psychiatric provider and MD. The DON stated the social worker would also talk to residents to ensure there were no psychological needs. The DON stated that psychiatric NP talked with Resident #1 and Resident #2 and that the social worker talked with Resident #1 and it should be documented under progress notes. The DON stated she spoke to Resident #1 and Resident #2 several days, multiple times a day and stated Resident #1 had not talked about the incidents for a few days. The DON stated that the incident on 07/12/2025 was discussed in shift report and ADON was in contact with the nurses. The DON stated she expected information about the incidents to be on the shift report. The DON stated nurse that worked on 07/13/2025 should have been aware that an incident occurred with Resident #1 and Resident #2 on 07/12/2025. Requested any documentation related 1:1 supervision at this time. During an interview on 07/21/2025 at 2:30 PM, the ADM stated he was notified on 07/12/2025 at 11:30 AM by the nurse that Resident #1 and Resident #2 were in the dining room and had an argument, The ADM stated that it was reported that Resident #1 changed the channel as Resident #2 watched previews and Resident #2 hit him with an open hand. The ADM stated no medical intervention was needed and there was no redness and no pain. The ADM stated he spoke with AD and the ADON took statements from Resident #1 and Resident #2 and an in-service was started on abuse and neglect and resident to resident altercation. The ADM stated interventions were to encourage Resident #1 and Resident #2 to stay away from each other since they already resided on separate halls. The ADM stated oncoming staff were informed of incident because it was noted on the 24 hour report and huddles during shift changes and constant flow of calls and the ADON follow up with staff. The ADM stated it was the charge nurses responsibility to notate incidents on the 24-hour report because they were responsible for informing the CNAs. The ADM stated that on 07/13/2025 he was notified by a nurse and the ADON than an incident occurred. He stated it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676292 If continuation sheet Page 5 of 7 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 676292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Luling 501 W Austin St Luling, TX 78648 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 0600 Level of Harm - Actual harm Residents Affected - Few reported that Resident #1 stumbled and grabbed a wheelchair to brace himself and Resident #2 hit Resident #1 on the left arm. The ADM stated it was reported by ADON there were no witnesses. Resident #1 reported to the ADM that he was hit on 07/13/2025 but Resident #2 reported he hit Resident #1 on 07/12/2025 and not on 07/13/2025 . The ADM stated there was no injury on 07/13/2025 to Resident #1. The ADM stated it was decided to place Resident #2 on 1:1 supervision because at the time the ADM was under the impression Resident #1 was hit by Resident #2. The ADM stated he was aware of redness to Resident #1 on 07/13/2025 but did not hear about a handprint. The ADM stated he reviewed incident reports and probably skimmed over the incident report for the 07/13/2025 incident. The ADM stated incidents were discussed during morning meetings. The ADM stated for the situations that occurred he sought counsel with regional nurse consultant, regional vice present and see what interventions needed to be put into place and it was discussed to put Resident #2 on 1:1 supervision until he could speak with the psychiatric nurse practitioner. The ADM stated that 1:1 supervision was when the staff stayed close to the resident and close enough to intervene to de-escalate a situation. He ADM stated he expected staff to document every shift regarding 1:1 and if there were any concerns. The ADM stated that ADON reported extra staff were brought in for 1:1 supervision and rotated every hour. The ADM stated he spoke with the psychiatric NP after in-person visits and she was comfortable to take Resident #2 off 1:1 supervision. The ADM was unsure of the date Resident #2 was removed from 1:1 supervision. During an interview on 07/21/2025 at 2:35 PM, the regional nurse consultant stated that documentation was expected to be that 1:1 occurred each shift in a progress note. Review of the staffing schedule for 07/13/2025, 07/14/2025, 07/15/2025, 07/16/2025 and 07/17/2025 did not reflect who was assigned or who was responsible for 1:1 supervision of Resident #2. Review of the staffing schedule for 07/15/2025 reflected a note written that Resident #2 remained on 1:1 and aides needed to rotate every hour. The note did not reflected who it was written by. Review of the 24 hour report dated 07/12/2025 and 07/13/2025 reflected to call police if Resident #2 hit another resident and case number was listed. Review reflected Resident #1 was very upset and to keep him away from Resident #2 and must have 1:1. CNA had log and must turn into ADM in AM. No presence or lack of additional behaviors noted. The note did not reflected who it was written by. Review of the 24-hour reported dated 07/14/2025 reflected under 10:00 pm to 6:00 am note Resident #2 was 1:1 with staff for incident with Resident #1. Presence or lack of behaviors not notated. Further review under 2:00 pm to 10:00 pm nursing remarks reflected Resident #2 was 1:1 with no distress noted. The note did not reflected who it was written by. Review of the 24-hour report dated 07/15/2025 reflected under 10:00 pm to 6:00 am nursing remarks Resident #2 had altercation with another resident, and Resident #2 was 1:1 and resting. The note did not reflected who it was written by. Review of the 24-hour report dated 07/16/2025 reflected under 10:00 pm to 6:00 am nursing remarks Resident #2 was on 1:1 due to altercation with another resident. No information regarding presence or lack of behaviors noted. The note did not reflected who it was written by. Review of the PIR dated 07/17/2025 reflected Resident #1 and Resident #2 were in the dining room and Resident #2 hit Resident #1 on the upper arm and upper thigh. Review of steps taken to immediately ensure residents were protected reflected residents were separated and that residents calmed down within a few minutes and psychiatric consults were scheduled. Review of the PIR dated 07/18/2025 reflected Resident #1 grabbed Resident #2's wheelchair to brace himself in the dining room and Resident #2 became upset and hit Resident #1 with slight redness noted to Resident #1's arm. Review of steps taken to immediately ensure residents were protected were noted as residents being separated, psychiatric consults scheduled and Resident #2 was placed on 1:1 supervision pending in-person psychiatric consult. PIR included discharge note dated 07/14/2025 was provided to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676292 If continuation sheet Page 6 of 7 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 676292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Luling 501 W Austin St Luling, TX 78648 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #2 with date of discharge at 08/13/2025. Review of the facility in-service dated 07/07/2025 reflected topic of ANE power point was reviewed with all staff. Review of power point included definition of abuse as the willful infliction of injury that results in physical harm, pain or mental anguish. Further review reflected facility responsibility included to documentation all relevant facts and actions. Review of the facility in-service dated 07/12/2025 reflected in-service was conducted with staff over facility policies related to resident-to-resident altercations and abuse, neglect and exploitation. Review of the facility in-service dated 07/13/2025 reflected in-service was conducted with staff over facility policies related to resident-to-resident altercations and abuse, neglect and exploitation. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program with revision date of 04/2021 reflected there was a facility -wide commitment to support the protection of residents from abuse, neglect and exploitation and included abuse from other residents. Further review reflected the facility should implement measures to address factors that may lead to abuse situations.Review of the facility policy titled Resident-to-Resident Altercations with revision date of September 2022 reflected staff monitored resident for aggressive / inappropriate behaviors towards other residents or staff. If residents are involved in an altercation staff should separate the residents and institute measures to calm the situation, review the events with the nursing supervisor and DON and evaluate the effectiveness of interventions meant to address distressed behavior for one or both residents. Review reflected staff were to document in the resident's clinical record all interventions and their effectiveness. Event ID: Facility ID: 676292 If continuation sheet Page 7 of 7