Based on observation, interview, record review, and facility policy review, the facility failed to protect residents right to be free from verbal, mental, and physical abuse for two (2) of four (4) sampled residents (Resident #2 and Resident #3). Specifically, Certified Nurse Aide (CNA) #1 verbally and physically abused Resident #2 during incontinence care on 5/21/25 by striking the resident's legs, scolding him, and failing to provide care in a safe, supportive, and respectful manner, resulting in the resident experiencing fear, shame, emotional distress, and feelings of helplessness. Additionally, CNA #1 verbally and mentally abused Resident #3 on 5/21/25 by scolding and berating the resident for incontinence, causing the resident to feel humiliated, ashamed, and fearful that the behavior would recur. Findings Included: Record review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, revealed, .Purpose: To prohibit and prevent abuse, neglect .Definitions: Abuse: The willful infliction of .intimidation .with resulting physical harm, pain or mental anguish. A record review of the Investigation Template, dated 5/21/25, revealed the facility described the allegation that Resident #2 reported that a CNA had hit him on the leg with both hands because he was wearing a condom catheter. The Investigation Summary indicated that Interviews with all residents with BIMS (Brief Interview for Mental Status) greater than eleven. A review of the Summary of Interview revealed Resident #2 stated he was hit last night on his legs. Another Summary of Interview revealed Resident #3 indicated The CNA .that was assigned to him on 11pm-7pm was pissed off with him because he had urinated in the bed and she had to change him. Resident #2 Record review of the admission Record revealed the facility admitted Resident #2 on 5/09/25 with current diagnoses including Urinary Tract Infection. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. Further review revealed Resident #2 had no behavioral issues, was always incontinent of bowel and bladder, and was dependent for toileting hygiene and required substantial/maximal assistance to roll left and right on bed. Record review of the Social Services Progress Note for Resident #2, dated 5/21/25 at 14:49 (2:49 PM) revealed the Social Services and Admissions Liaison (SSD) documented that she visited the resident to ask about the incident that happen over night with the CNA. I let him know that we would handle the situation asap (as soon as possible). That we would make sure nothing like this ever happened again to him or anyone else. On 6/02/25 at 11:45 AM, an interview with Resident #2 with the assistance of his communication device revealed the resident stated that during the early hours of 5/21/25 Certified Nurses' Aide (CNA) #1 entered his room and discovered that his condom catheter had come off and his incontinence brief was wet, and he thought she acted like she got mad. He reported that when she started to turn him during incontinence care he had muscle spasms in his legs and the CNA struck him twice on his legs and told him to stop tensing up. He said he had involuntary muscle spasms and took medication for them. He said that he had not tried to communicate with the CNA after she struck him because he was scared. He said this incident upset him because he was dependent and could not defend himself. He said he immediately wanted to go home because nobody treated him like that at home, and he was afraid because the incident could occur again. He said that he was unable to go back to sleep and cried due to feeling afraid and humiliated. He confirmed the incident caused him to feel shame, fear and demeaned. He said he only agreed to remain at the facility after being assured that CNA would not be allowed back into his room and confirming that his wife could stay with him at night until he could complete his therapy and return home as scheduled. On 6/02/25 at 12:10 PM, an interview with the Resident Representative (RR) for Resident #2 revealed she had been notified of the resident's allegation of abuse on 5/21/25. She stated that when she arrived, he was very upset and demanded to go home immediately. She stated that her immediate reaction was to take him home, but that he was doing very well with his therapy and the two of them agreed for him to stay with her spending nights in his room with him. On 6/02/25 at 2:25 PM an interview with CNA #2 revealed she reported she had worked 7-3 shift on 5/21/25 and at approximately 7:30 PM she entered the room of Resident #2, and he was resting in bed with tears on his face and crying. She said she asked him what was wrong, and he used his communication device to tell her that he had been hit. She said she asked him who hit him, and he typed in the name of CNA #1. She stated that the resident told her he had been scared and crying and wanted to go home because no one hit him at home. She said she had immediately reported the allegation of abuse to the former Assistant Director of Nursing Services (ADNS). Resident #3 Record review of the admission Record revealed the facility admitted Resident #3 on 3/27/25 with current diagnoses including Benign Neoplasm of Cerebral Meninges. Record review of the admission MDS with an ARD of 4/03/25 revealed Resident #3 had a BIMS score of 8, which indicated his cognition was moderately impaired. Further review revealed he had no behaviors, was always incontinent of bowel and bladder, and required substantial/maximal assistance for toileting hygiene and moderate assistance to roll left and right on bed. On 6/02/25 at 3:50 PM during interview with Resident #3 in his room, he revealed that during the early morning hours of 5/21/25, CNA #1 had entered his room and scolded him for wetting his bed. He said that made him feel ashamed and said, I can't help wetting the bed; if I could, I wouldn't do it. It made me feel like getting up and getting out of here and I would have if I could. The resident said the incident made him feel shame and humiliated for wetting the bed and he was afraid because CNA #1 intimidated him while scolding him and that he was afraid the incident may recur. On 6/03/25 at 2:54 PM, during a telephone interview the former ADNS, she stated that she was the nurse assigned to the care of Resident #1 on 5/21/25 and was made aware of an allegation of abuse by Resident #2 around 7:30 AM by CNA #2. She said she immediately assessed and interviewed Resident #2 who was actively crying and told her that CNA #1 had hit his legs during the earlier hours of 5/21/25 when he wet his brief and then had muscle spasms in his legs during incontinence care and berated him to stop tensing up. She reported she had also assessed the resident, and his condom catheter was off, but in his brief. She said she had spoken with CNA #1 at approximately 6:45 AM on 5/21/25 and the CNA had asked her if the resident had any more condom catheters. She stated that the resident was traumatized and that on 5/21/25 the resident's wife had started spending the night with the resident in his room. She said that she was unaware of any other complaint ever made by Resident #2. She stated that as part of the investigation into Resident #2's allegation, she interviewed and assessed Resident #3 who reported that CNA #1 had scolded him because he had wet his bed. On 6/04/25 at 9:30 AM, during a telephone interview the District Ombudsman revealed she had received a report from the RR for Resident #2 that the resident had been struck by CNA #1 who spoke to him in a demeaning manner that made him feel degraded. She said the facility staff reported that CNA #1 had confirmed tapping the resident's leg. The Ombudsman said that there was no report given to her that Resident #3 had also reported verbal or mental abuse by CNA #1 during the same shift. On 6/04/25 at 10:35 AM, an interview with the Social Services and Admissions Liaison (SSD) revealed she was made aware of the allegation of abuse by Resident #2 on the morning of 5/21/25, a little after 8:00 AM and visited him on 5/21/25 to make sure he wasn't too upset and see if I needed to try to make him feel better and reiterate to him that the incident wouldn't happen again. She stated that she recalled somebody said something about Resident #3 saying CNA #1 got upset with him because he wet his bed but she did not visit the resident. On 6/04/25 at 11:11 AM, an interview with the Director of Nursing Services (DNS) revealed she was made aware of the allegation of abuse reported by Resident #2 by the Administrator at home on the morning of 5/21/25 via telephone call. She stated that she called CNA #1 and notified her that she was suspended pending investigation. She stated she had completed a couple of coaching sessions with CNA #1 in November 2024 related to resident care and Resident Rights and the CNA's assignment was changed to another group for the resident's comfort. She stated she became aware of the allegation of abuse by Resident #3 when she read the final draft of the investigation prior to sending it to the State Agency (SA) on 5/24/25. She stated that she was not aware of any follow-up investigation, interventions, or counseling provided as a result of the allegation by Resident #3. She said she felt CNA #1 had adequate information and training to provide appropriate care for Resident #2 and Resident #3. On 6/04/25 at 11:25 AM, during a telephone interview with CNA #1, she said she had 'patted' Resident #2 on his leg to get him to relax during incontinence care on the morning of 5/21/25. She stated it was possible she was frustrated. She said Resident #2 had never acted like that before, never tensed up before. It's harder on me. She explained that she had entered the room to empty the resident's catheter drainage bag, but it was empty, and she checked his brief, and it was wet. She noted his condom catheter had come off and she had to provide incontinent care and change his brief. She said she had told him that she was going to have to change his brief and when she started to turn him, his legs were tensed up and she was unable to turn him. She said she patted his leg and told him to relax and was then able to turn him onto his side and completed incontinence care. She said nobody ever told her that Resident #2 had muscle spasms. She said that Resident #2 used a communication device that was always on his over the bed table but that the device was not in his reach and he did not have it, and she did not give it to him. She said, When I talk to him, I try to understand him without using the tablet. I didn't use or give him the tablet. She said the resident didn't say anything to her. She reported that when she made final rounds, she entered Resident #3's room and was frustrated with him because he had peed out the bed. I think it was intentional. CNA #1 said she had fussed at Resident #3 and said, I shouldn't have, but I did. I told him he needed to stop urinating in bed. I had to change the bed and his clothes and give him a bed bath three (3) times during the shift. She said Resident #3 didn't respond. She said the DNS had called her at home and she had to meet with the DNS and the Administrator and was written up regarding the allegation by Resident #2 but was not asked any questions regarding Resident #3. She confirmed that she had complaints made against her and received coaching from the DNS in November 2024 and said, Usually I get changed to another hall. On 6/04/25 at 1:50 PM an interview with the Administrator revealed she was made aware of the allegation of abuse by Resident #2 on the morning of 5/21/25 by the ADNS. She said actions taken to protect the residents during the investigation included placing CNA #1 on suspension. She confirmed that the facility investigation determined the allegation of abuse was unfounded because there were no witnesses and no apparent injury such as bruise or abrasion. She acknowledged that Resident #2 had new behaviors of crying and had not made any allegations before or since the allegation of abuse voiced on 5/22/25 and she was aware that Resident #2's wife began to stay with him overnight in his room. She stated CNA #1 was brought back with training to educate regarding abuse and neglect prevention and resident rights and reassignment to a different group of residents.