**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to provide Resident (R)50 with sufficient daily fluid intake, for 1 of 1 resident reviewed for hydration. Findings include: Review of the facility policy titled Intake and Output last revised October 2023 revealed, To maintain an accurate record of the resident's fluid intake and output. Documentation of intake and output are indicated when there is a change in the resident's intake or output, when intravenous fluid are being administered, or when a resident is on a fluid restriction. Procedure includes identify resident, use both resident's identification bracelet and resident photograph on unit. Record all fluid intake, a cup of ice is equal to approximately mL (milliliter) of fluid, record all intake, every shift. Review of R50's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to: schizophrenia, congestive heart failure, and dementia with agitation. Review of R50's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/28/25, revealed that R50 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicates that R50 is cognitively intact. Further review of the Quarterly MDS revealed that R50 requires set up or clean up assistance with the Activities of Daily Living (ADL) task of eating. R50 has no issues with swallowing or nutritional status. During an observation and interview on 04/15/25 at 12:59 PM, R50 was in her in bed with a water jug of 500 liters of water. During interview with R50 she stated that staff do not provide her adequate hydration during day and the only times she receives fluids are during mealtimes and when she gets her medications. Further interview with R50 stated that the last time staff offered to provide her hydration in her water jug was about 2 weeks ago. R50 stated I do not want to drink water that has been sitting for days because it is not fresh. Observation of the 500 liters of water revealed no ice or condensation on the outside of the water jug, it appeared to be room temperature. During an interview on 04/17/25 at 3:55 PM, R50 stated that again today no staff provided her hydration other than with her meals or medications. Review of R50 Intake/Output Monitoring Report for January 2025, revealed the following dates recorded for fluid intake: -01/07/25 at 10:23 AM - 420 mL -01/13/25 at 10:29 AM- 240 mL -01/21/25 at 5:36 PM - 240 mL -01/22/25 at 8:36 AM - 480 mL -01/25/25 at 8:00 PM - 720 mL The record of fluid intake was missing for multiple days in the month of January 2025. There was no other documentation found for the month of January 2025 for R50 Intake/Output monitoring. Record review of R50 Intake/Out Monitoring Report for February 2025, revealed the following dates recorded for fluid intake: -02/01/25 at 7:00 AM - 420 mL -02/01/25 at 7:00 AM - 420 mL -02/03/25 at 6:39 PM - 240 mL -02/10/25 at 10:26 AM - 420 mL -02/10/25 at 10:27 AM - 420 mL -02/11/25 at 8:49 PM - 240 mL The record of fluid intake was missing for multiple days in the month of February 2025. There was no other documentation found for the month of February 2025 for R50 Intake/Output monitoring. Record review of R50 Intake/Output Monitoring Report for Mach 2025, revealed the following dates recorded for fluid intake: -03/07/25 at 8:30 PM - 240 mL -03/12/25 at 10:26 PM - 240 mL -03/25/25 at 1:10 PM - 120 mL -03/25/25 at 1:10 PM - 420 mL -03/29/25 at 2:34 PM - 420 mL -03/29/25 at 2:34 PM - 420 mL The record of fluid intake was missing for multiple days in the month of March 2025. There was no other documentation found for the month of March 2025 for R50 Intake/Output monitoring. Review of R50's Intake/Output Monitoring Report for April 2025, revealed the following dates recorded for fluid intake: -04/09/25 at 1:11 PM - n/a The record of fluid intake was missing for multiple days in the month of April 2025. There was no other documentation found for the month of April 2025 for R50 Intake/Output monitoring. Review of R50's Care Plan last revised on 12/04/24, revealed, [R50] has the potential for complications related to multiple medical problems as evidence by diagnosis of cardiac issues, respiratory issues, history of Urinary Tract Infection, hypertension, gastrointestinal (GI) bleed/anemia . interventions include encourage to drink fluid on meal tray, with medications, and during hydration rounds. During an interview on 04/17/25 at 6:17 PM, the Unit Manager revealed that her expectation is for staff to document resident's input/output for hydration on every shift. During an interview on 04/17/25 at 6:45 PM, the Director of Nursing revealed that their expectation is for staff to document resident's intake/output monitoring in the Electronic Medical Record (EMR) every shift. During an interview on 04/18/25 at 9:55 AM, the Nurse Consultant revealed that the facility was unable to locate any additional documentation for R50 related to her intake/output monitoring for 2025.

Amended 1/9/25 Based on interview, record review, and facility document and policy review, the facility failed to timely report an allegation of abuse to the state survey agency for 1 (Resident (R)4) of 3 sampled residents reviewed for abuse. Findings included: 1. A facility policy titled, Protection From Harm Program, revised 11/2024, indicated the facility will report all incidents of alleged or substantiated abuse to the proper government agencies as outlined by state, federal and local regulations governing the operation of a long-term nursing care facility. The policy revealed DHEC [Department of Health and Environmental Control] requires the reporting of Resident-to-Resident abuse, altercations involving physical contact between two residents. A Face Sheet indicated the facility admitted R3 on 03/21/2023. According to the Face Sheet, the resident had a medical history that included diagnoses of dementia, type 2 diabetes mellitus, encephalopathy, wandering, and schizophrenia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/10/2024, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. R3's Care Plan Report included an undated problem statement, that indicated the resident had behavioral symptoms that included being resistant to care; noncompliant with care/medications; combative; hard to redirect; easily agitated by others (yelling out, loud disruptions); unpredictable behaviors with episodes of verbal threats of physical aggression towards staff and peers without provoking; spitting towards staff and peers; ineffective understanding of safety; threatening and taunting behavior with attempts to break facility equipment by punching, kicking, and grabbing materials which are thrown at staff. A Face Sheet indicated the facility admitted R4 on 10/20/2022. According to the Face Sheet, the resident had a medical history that included diagnoses of schizophrenia, schizoaffective disorder, and altered mental status. A quarterly MDS, with an ARD of 09/19/2024, revealed R4 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. An Initial Report, dated 11/16/2024, indicated the facility was informed of an allegation of resident-to-resident abuse on 11/15/2024 at 7:25 PM. A facsimile report dated 11/16/2024, indicated the facility notified the state survey agency of the abuse allegation on 11/16/2024 at 10:51 AM. Per the Initial Report, R3 alleged that R4 pulled their leg and spat on them. During an interview on 12/05/2024 at 12:30 PM, the Director of Nursing stated it was her expectation that facility staff report alleged abuse allegations timely based on facility policy and regulatory guidelines. During an interview on 12/05/2024 at 12:32 PM, the Administrator stated it was her expectation that facility staff report alleged abuse allegations timely based on facility policy and regulatory guidelines.

Based on interview, record review, document review, and facility policy review, the facility failed to provide supervision to prevent accidents for 1 (Resident #3) of 3 sampled residents reviewed for abuse. Specifically, staff were required to keep Resident #3 within line of sight when the resident was out of their room. On 11/15/2024 at approximately 7:25 PM, staff failed to supervise Resident #3 and found the resident in Resident #4's room. Findings included: A facility policy titled, Special Treatment Modalities and Observation Levels effective 09/2024, revealed, This directive defines the process for administering care to resident populations who because of their behavior/condition, require more intensive monitoring within the facility. It is the policy of [the facility] to provide an appropriate level of supervision for those residents who are at significant risk of harm to self and/or others and/or who may create serious disruption in the environment. The policy revealed, Constant Observation-Line of Sight (COLS): Occurs when an individual staff member may be responsible for up to two (2) residents who remains at all times within the line of sight of the assigned staff. A Face Sheet indicated the facility admitted Resident #3 on 03/21/2023. According to the Face Sheet, the resident had a medical history that included diagnoses of dementia, type 2 diabetes mellitus, encephalopathy, wandering, and schizophrenia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/10/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. According to the MDS, the resident had physical and verbal behavioral symptoms directed toward others one to three days during the assessment period. The MDS revealed the resident used a manual wheelchair and was independent for sit to stand and chair/bed-to-chair transfer and with walking up to 150 feet. Resident #3's Care Plan Report included an undated problem statement, that indicated the resident had behavioral symptoms that included being resistant to care; noncompliant with care/medications; combative; hard to redirect; easily agitated by others (yelling out, loud disruptions); unpredictable behaviors with episodes of verbal threats of physical aggression towards staff and peers without provoking; spitting towards staff and peers; ineffective understanding of safety; threatening and taunting behavior with attempts to break facility equipment by punching, kicking, and grabbing materials which are thrown at staff. Interventions directed staff to provide special treatment modalities and observation levels per physician orders. The intervention indicated that staff may observe the resident up to ten feet away (initiated 01/01/2023). The facility Five-Day Follow-Up Report, dated 11/22/2024 revealed it was reported that on 11/15/2024 at 7:25 PM, Resident #3 entered Resident #4's room, during shift change and pulled Resident #4's leg. The report revealed that upon investigation, video footage showed Resident #3 coming down the hall from the nurse's station via wheelchair and going to the doorway of Resident #4's room. Video footage showed Resident #3 stood up and entered Resident #4's room. After approximately 30 seconds, the video footage showed two staff members at the doorway of Resident #4's room directing Resident #3 to come out. Per the facility's report, video footage showed Resident #3 left the room and sat in their wheelchair. The report revealed the two staff members stated that they heard Resident #4 saying not to spit or kick them as the staff approached Resident #4's room. Per the report, when they arrived at Resident #4's room, the staff saw Resident #3 pulling Resident #4's leg. The report revealed Resident #3 had a history of aggression towards peers and staff. Per the report, Resident #4 had a history of agitation, yelling, and being verbally aggressive toward staff and others. According to the report, the facility conducted an investigation that included obtaining staff witness and resident statements, conducting record review, and reviewing camera footage. The report revealed the facility determined that Resident #3 entered Resident #4's room where an inappropriate exchange occurred between the residents and neither resident sustained an injury. Per the report, facility staff quickly intervened once Resident #3 entered the room; psychiatry evaluated Resident #4 and Resident #3 and medication adjustments were made, and Resident #3 would remain on continuous line of sight supervision. Per the report, based on the evidence, the facility could not determine Resident #3's intent when they entered Resident #4's room; subsequently, abuse could not be substantiated. Resident #3's 1:1 Observation Flowsheet-Nursing Service for 11/15/2024, revealed staff should observe [the resident] every hour and CLOS when out of room due to Risk of Injury to Others. Per the flowsheet, at 7:00 PM on 11/15/2024, Certified Nursing Assistant (CNA) #7 documented that Resident #3 was in the hallway and in the resident's room. The flowsheet revealed no further documentation regarding Resident #3's location until 8:00 PM. During an interview on 12/02/2024 at 1:55 PM, Registered Nurse (RN) #19 stated that Resident #3 required continuous observation when the resident was out of their room. During a telephone interview on 12/03/2024 at 2:14 PM, RN #9 stated he was unable to explain how Resident #3 was able to go into Resident #4's room when Resident #3 was supposed to be supervised when out of their room. During an interview on 12/03/2024 at 4:41 PM, CNA #12 stated she started work on the day of the incident at 7:00 PM. CNA #12 stated during the beginning of shift change she noticed an empty wheelchair in front of Resident #4's room. CNA #12 indicated that she saw Resident #3 standing over Resident #4 pulling the resident's leg as if the Resident #3 was trying to put Resident #4's leg back on the bed. Per CNA #12, Resident #4 stated that Resident #3 kicked and spat on them. CNA #12 indicated that she did not witness Resident #3 spitting or kicking Resident #4. CNA #12 indicated that when Resident #3 was out of their room, a TA was supposed to be observing Resident #3. CNA #12 indicated that there was no TA who sat near the nurse's station when she started work at 7:00 PM. During an interview on 12/04/2024 at 2:50 PM, CNA #8 stated Resident #3 was usually a protector of the residents. CNA #8 indicated that she had never seen Resident #3 go in another resident's room. CNA #8 stated she was not aware she was assigned TA duties on the day of the incident until CNA #7, who was leaving, notified her. CNA #8 indicated that when she came in to work, Resident #4 was in bed and requested assistance to sit in their chair. CNA #8 stated she went to get CNA #12 to assist her with getting Resident #4 to a chair. CNA #8 stated they found Resident #3 was in Resident #4's room. Per CNA #8, CNA #12 redirected Resident #3 out of the room and reported the incident to the RN #9. During an interview on 12/04/2024 at 4:49 PM, CNA #7 stated that on the day of the incident, the TA left early due illness, and she took over the observation of residents until 7:00 PM. CNA #7 indicated that during the time she watched residents in the hallway, Resident #3 did not come out of their room. CNA #7 indicated that she was due to get off at 7:00 PM and was at the nurses' station assisting the nurse when the incident occurred. CNA #7 further indicated that CNA #8, was supposed to be assigned TA duties at 7:00 PM, and was supposed to observe residents that were in the hallway. During an interview on 12/04/2024 at 12:25 PM, the Director of Nursing stated that it was her expectation that the staff follow facility and regulatory guidelines related to preventing abuse and keeping residents safe. During an interview on 12/04/2024 at 12:30 PM, the Administrator stated that it was her expectation that the staff follow facility and regulatory guidelines related to preventing abuse and keeping residents safe.

Based on record review, facility policy review, and interviews, the facility failed to ensure allegations of abuse were reported timely for 1 (Resident (R)11) of 11 residents reviewed for abuse. Findings included: The facility's policy, titled, Protection From Harm Program, dated November 2022, indicated, A significant aspect of resident's rights is the right to be free from abuse/neglect. The facility will have a zero tolerance for any type of abuse. The policy indicated, If a covered or non-covered [facility] employee or agency staffing member has reason to believe that a resident has been or is likely to be abused, neglected or exploited or if a covered or non-covered [facility] employee or agency staffing member suspects that a resident has been a victim of any other crime they must insure safety of the resident and report the incident immediately, within 24 hours, but no longer than 24 hours. If serious bodily injury has occurred then the report must be made within two hours. A review of R11's Face Sheet revealed the facility admitted the resident on 02/14/2023 with diagnoses that included type 2 diabetes mellitus, schizoaffective disorder- bipolar type, neurocognitive disorder, unsteadiness on feet, and difficulty walking. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2023, revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident had delusions but did not have any behavioral symptoms. A review of R11's Care Plan Report, initiated on 02/22/2023, indicated the resident had the potential for impaired psychosocial functioning related to diagnoses of major neurocognitive disorder and schizoaffective disorder and recent admission to a new facility. Interventions directed staff to introduce themselves to the resident and explain their role in the resident's care, maintain a calm, therapeutic environment, and a structured routine. The care plan also indicated for staff to observe for any changes or decline in cognition, mood, or behavior and to report to the medical doctor/psychiatrist. A review of the facility's [Facility Name] Incident Report, dated 02/28/2023, revealed that on 02/27/2023, Speech Language Pathologist (SLP) #26 witnessed a verbal interaction between Certified Nursing Assistant (CNA)17 and R11. CNA17 made a statement that caused the resident to become upset. R11 responded with profanity and upon returning to their room, the resident stated, I want to leave; he may try to do something while I'm sleeping. SLP #26 reassured the resident that nothing would happen, and no one would harm the resident. Further review of the report revealed there was no injury to R11; however, the SLP did not report the incident until 02/28/2023, the day after the incident. During an interview on 04/27/2023 at 12:50 PM, Speech Language Pathologist SLP26 stated R11 was on therapy case load for skilled services. After the dinner meal on 02/27/2023 at 5:11 PM, in the hallway, staff were picking up the dinner trays for the residents that had completed their meals. SLP26 stated she observed CNA #17 with a tray in his hand. R11 was coming out of the dayroom into the hallway. CNA17 stated to the resident, Move out of the way, you are moving too slow. During that time, R11 was pushing their wheelchair and said their legs were weak. CNA17 then repeated the statement, You are moving too slow. Also, CNA17 stated to the resident, They will send you back where you came from. At that point, the resident turned around and addressed CNA17's comment with profanity. CNA17 again repeated, They are going to send you back where you came from. SLP26 stated a nurse from night shift duty was also present at the time and was assisting with collecting trays. SLP26 stated the nurse approached her and said, I did not perceive the situation as abuse. SLP26 revealed she spoke with RN #18 on 02/28/2023 at 8:48 AM, the next day, and informed her of the situation, and an abuse report was filed. During an interview on 04/27/2023 at 8:15 AM, Licensed Practical Nurse (LPN)13 indicated she was familiar with R11. The resident was very pleasant and cooperative. LPN13 stated the resident came from a bullying environment from their last facility. She stated that regarding the incident with R11, she had just walked up on the situation while gathering trays and heard CNA17 say to the resident, You got to speed it up; I don't want them to send you back. Therefore, it caused the resident to trigger and instantly become aggressive with profanity, and the resident replied, I'm not going back there. There was no documented evidence LPN13 reported the incident as an allegation of abuse. LPN13 stated she felt it was an educational moment for CNA17. During an interview on 04/28/2023 at 6:23 PM, the Director of Nursing (DON) stated as soon as she was made aware of the abuse allegation, on 02/28/2023, she reported to all the appropriate authorities. The DON stated reporting was a must. She stated even if staff were not sure, it must be reported. During an interview on 04/28/2023 at 7:35 PM, the Administrator stated it was her expectation that staff ensure resident safety by reporting immediately.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the care plan was implemented for 1 (Resident (R)12) of 4 sampled residents reviewed for accidents. The facility developed a care plan that included an intervention that required staff to provide one on one supervision for R12 due to fall risk and a fractured clavicle. However, on 03/28/2023, the facility failed to supervise R12, and the resident sustained a fall. Findings include: A review of the facility's Resident Care Conference policy, dated February 2023, indicated, Resident Care Conferences (RCC) are herby established for the purpose of providing the most effective utilization of available resources in the planning and re-evaluation of an individualized care and treatment plan which is based on a comprehensive assessment. The RCC of each unit shall meet weekly. Special reviews are scheduled as needed. All staff engaged in any aspect of the care of residents are considered members of the RCC. There was no documented evidence the policy addressed the facility's procedure for ensuring resident care plans are implemented. A review of a Face Sheet indicated the facility admitted R12 on 06/03/2019 with diagnoses that included schizophrenia, schizoaffective disorder, bipolar type, unspecified dementia with behavioral disturbance, age related osteoporosis (bone disease), restlessness, and agitation. A review of R12's annual Minimum Data Set (MDS), with an Assessment Reference Date of 02/01/2023 revealed the resident had a Brief Interview for Mental Status (MDS) score of 0, which indicated the resident was severely cognitively impaired. According to the MDS, R12 was independent with bed mobility, transfers, and walking. According to the MDS, the resident had not sustained any falls since the previous MDS assessment. Review of R12's Care Plan, dated 02/08/2023, revealed the resident was at risk for falls related to impaired safety awareness, cognitive deficits, use of psychotropic medication, weakness, unsteady gait, and a history of sitting on the floor. On 02/24/2023, the facility revised the resident's care plan with an intervention that directed staff to provide one-on-one observation due to fall risk and a fractured clavicle. A review of the [Facility Name] Incident Report, dated 03/29/2023 at 7:30 AM, indicated staff responded to a scream from the hallway, at 12:00 AM on 03/29/2023, and observed R12 on the floor. The resident stated, I fell down, and My knee hurt. A left knee abrasion that measured 1 centimeter (cm) by (x) 1 cm was noted. The protective devices/measures that were in use at the time of the incident included hipsters, half side rails, and a bed in low position. There was no documented evidence that one-on-one observation was implemented at the time of the fall. A review of Therapeutic Assistant (TA)20's witness statement dated 03/29/2023 at 12:15 AM, indicated she was assigned to supervise R12 on 03/28/2023, beginning at 11:30 PM, The statement revealed TA20 had to leave the room to use the restroom and did not have time to ask another staff to relieve her. She indicated that as she came from the bathroom, she heard the resident screaming. Attempts were made to contact TA20 for an interview on 04/26/2023 at 8:50 AM and at 5:50 PM, and on 04/27/2023 at 10:00 AM. There was no answer nor a voicemail option. During an interview on 04/27/2023 at 8:40 AM, Licensed Practical Nurse (LPN)1 revealed she was the charge nurse on the unit when the fall occurred. She stated before 1:00 AM that morning, she heard R12 scream. When LPN1 entered the room, TA20, who was assigned to monitor the resident one-on-one, came from the hallway, and said she had to leave to go to the bathroom right away. LPN1 stated she was aware TA20 was previously sick and had been off work; however, the LPN stated the TA should not leave a resident that was as impulsive as R12 and had a recent history of falls. LPN1 also stated that the resident had a shoulder injury from a previous fall and must be monitored closely. During an interview on 04/26/2023 at 2:50 PM, Medical Doctor (MD)7 revealed due to R12's impulsive behavior, attempts to self-transfer, and fall risk, staff must monitor the resident closely in their room and with transfers. The resident had previously had a clavicle fracture and she was concerned the resident reinjured their clavicle. Also, she was concerned that the staff left the resident alone and the resident had another unwitnessed fall when one-on-one supervision was required. MD7 stated the staff must monitor residents for their safety. During an interview on 04/28/2023 at 6:23 PM, the Director of Nurses (DON) stated R12 was required to have constant one-on-one supervision and monitoring. She stated the staff member (TA20) should never leave a resident without notifying someone to get relief. Unfortunately, TA20 did not follow the orders nor the facility's expectations with R12, and the resident had another fall. The DON stated this was a perfect example of what could happen if interventions were not implemented. She stated the incident put the resident at further risk. During an interview on 04/28/2023 at 7:35 PM, the Administrator stated, like care plans, it was the facility's goal to prevent falls from happening and to protect residents from harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, video footage review, and facility policy review, the facility failed to protect 3 (Residents (R)11, R3, R15) of 11 residents' right to be free from mental/verbal/physical abuse by staff and residents. Specifically, the facility failed to protect R11's right to be from verbal abuse by Certified Nursing Assistant (CNA)17; failed to protect R3's right to be free from physical abuse by R2; and failed to protect R15's right to be free from physical and mental abuse by Therapeutic Assistant (TA)27 and TA28. Findings include: The facility's policy, titled, Protection From Harm Program, dated November 2022, indicated, A significant aspect of resident's rights is the right to be free from abuse/neglect. [The facilities] have a zero tolerance for any type of abuse. The policy indicated, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy revealed, Instances of abuse of all residents, irrespective of any mental or physical condition cause harm, pain or mental anguish. 'Willful' as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Further review of the policy revealed, Physical Abuse means hitting, slapping, pinching, kicking, and includes controlling resident behavior through corporal punishment. The policy indicated, Verbal abuse means any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within the hearing distance, regardless of their age, disability or ability to comprehend. According to the policy, Covered and non-covered [facility] employees and agency staff will be held responsible in the prevention of abuse and neglect of all residents. Further review of the policy revealed, When circumstances suggest that an employee has abused, neglected or exploited a resident, the employee is advised of the allegation, informed of his/her legal rights and is immediately removed from the facility until the incident has been thoroughly investigated. This action allows for the employee to be safe from further accusations/confrontations with the accusing resident, family member, or other [facility] employees and agency staffing and for the resident to feel safe and secure. The resident, if necessary, will be afforded the opportunity to relocate to another area of the facility if he/she no longer feels comfortable in the present setting. Under no circumstances will the facility tolerate any type of repercussions to the resident or employee for making a complaint regarding abuse or suspected abuse. 1. A review of R11's Face Sheet revealed the facility admitted the resident on 02/14/2023 with diagnoses that included type 2 diabetes mellitus, schizoaffective disorder- bipolar type, neurocognitive disorder, unsteadiness on feet, and difficulty in walking. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2023, revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident had delusions but did not have any behavioral symptoms. A review of R11's Care Plan Report, initiated on 02/22/2023, indicated the resident had the potential for impaired psychosocial functioning related to diagnoses of major neurocognitive disorder and schizoaffective disorder, and related to being a recent admission to a new facility. Interventions directed staff to introduce themselves to the resident and explain their role in the resident's care and to maintain a calm, therapeutic environment, and structured routine. The care plan also directed staff to observe for any changes or decline in cognition, mood, or behavior and to report to the medical doctor/psychiatrist. A review of the facility's [Facility Name] Incident Report, dated 02/28/2023, revealed on 02/27/2023, Speech Language Pathologist (SLP) #26 witnessed a verbal interaction between CNA17 and R11. CNA17 made a statement that caused the resident to become upset. R11 responded with profanity and upon returning to their room the resident stated, I want to leave; he may try to do something while I'm sleeping. SLP26 reassured the resident that nothing would happen, and no one would harm the resident. Further review of the report revealed no injury to R11. A review of the facility's Accident/Incident Reporting Form, dated 03/03/2023, indicated that on 02/28/2023, SLP26 reported that on 02/27/2023 she witnessed a verbal interaction between CNA17 and R11. SLP26 overheard CNA17 tell R11 to move out of the way because the resident was moving too slowly. R11 responded to CNA17 by saying his/her legs were too weak, CNA17 then responded back to the resident and said, They will send you back where you came from. The resident stopped walking, turned around, and started using profanity at CNA17. After R11 returned to their room, the resident stated to SLP #26 that the resident wanted to leave because CNA17 may try to do something to them while sleeping. SLP26 explained to the resident that nothing would happen to them, and no one would harm the resident. When the Director of Nursing (DON) and Day Shift Supervisor interviewed CNA17 about the incident, CNA17 stated R11 was walking to their room, and as the resident walked past the CNA, the resident said they had to use the restroom. CNA17 stated he told the resident to hurry up, and he encouraged the resident to move faster. CNA17 stated he did not recall and was unsure whether he told the resident they would be sending the resident back where they came from. CNA17 was suspended and terminated. Further review revealed the facility substantiated that abuse occurred. During an observation and interview on 04/24/2023 at 10:20 AM, R11 was sitting on their bed in their room with no bruises or injuries observed. R11 stated no one had been mean or hurt them, and no one had made negative statements toward the resident. The resident did not recall any staff telling them to move out of the way or they were going to send them back. R11 denied the incident occurred. During an interview on 04/27/2023 at 12:50 PM, SLP #26 stated R11 received therapy from February 2023 to March 2023 related to the resident's history of dysphagia. SLP #26 stated the alleged abuse occurred on 02/27/2023 at 5:11 PM in the hallway. After the dinner meal, when staff were picking up the dinner trays for the residents that had completed their meals, SLP #26 stated she observed CNA17 with a tray in his hand. R11 was coming out of the dayroom into the hallway. CNA17 stated to the resident, Move out of the way, you are moving too slow. During that time, R11 was pushing their wheelchair and said their legs were weak. CNA17 then repeated the statement, You are moving too slow. Also, CNA17 stated to the resident, They will send you back where you came from. At that point, the resident turned around and addressed CNA17's comment with profanity. CNA17 again repeated, They are going to send you back where you came from. SLP26 stated a nurse from night shift was also present and was assisting with collecting trays. SLP26 stated the nurse approached her and said, I did not perceive the situation as abuse. The SLP stated at no point did CNA17 raise his voice or raise his hands to the resident. The CNA spoke in a leveled, non-elevated tone and nonaggressive actions. Further, SLP26 revealed she spoke with RN18 on 02/28/2023 at 8:48 AM, the next day, and informed her of the situation, and a report was filed. SLP26 also stated she had a conversation with the Administrator who told the SLP if she thought the incident was actual abuse on 02/27/2023, she should have reported immediately. During an interview on 04/27/2023 at 8:47 PM, CNA17 revealed he was no longer employed at the facility related to a false abuse allegation. CNA17 stated he recalled the incident with R11 well and briefly stated that he was only trying to motivate the resident to be more mobile and independent. CNA17 said that at no point in his health care career would he ever intentionally harm or verbally abuse a resident; however, if manipulating a resident to be more independent was abuse then, Yes, it was verbal abuse. During an interview on 04/27/2023 at 8:15 AM, Licensed Practical Nurse (LPN)13 revealed R11 came from another facility where staff created a bullying environment. She stated she had just walked up on the situation while gathering trays and heard CNA17 say to the resident, You got to speed it up; I don't want them to send you back. Subsequently, it caused the resident to trigger and instantly become aggressive, using profanity, and the resident replied, I'm not going back there. LPN13 stated she intervened, calmed the resident, removed CNA17 from the situation, and took over the resident's care. During an interview on 04/28/2023 at 6:23 PM, the DON stated verbal abuse did occur, and CNA17 was terminated. The DON stated abuse would not be tolerated at the facility and there was zero tolerance for any type of abuse. During an interview on 04/28/2023 at 7:35 PM, the Administrator also stated abuse of no type would be tolerated. He stated, We are a zero-tolerance facility. 2. A review of R15's Face Sheet revealed the facility admitted the resident on 03/212023, with diagnoses that included psychoactive substance use with persisting dementia, type 2 diabetes mellitus, encephalopathy, schizophrenia, and extrapyramidal and movement disorder. A review of R15's Care Plan Report, dated 03/23/2023, indicated the resident had altered thought processes and impaired decision making related to diagnoses of major neurocognitive disorder secondary to paranoid schizophrenia and depression. The resident had behavioral episodes of being combative and hard to redirect, a history of being agitated (poor insight and judgement), unpredictable behaviors with episodes of verbal threats of physical aggression, and ineffective understanding of safety. Interventions included for staff to provide one-on-one (1:1) observation for safety, observe and assess the resident's mood and behavior, observe for signs of psychological trauma such as increased agitation, and worried facial expression, change in sleeping pattern or appetite. Additional care plan interventions indicated staff should provide a calm therapeutic environment and structured routine, observe for escalating behaviors and be sure needs were met, when escalating behaviors were identified, remove the resident to a more quiet place and observe until behaviors are resolved; and if the resident was experiencing significant agitation that was impacting the resident's safety and the safety of others, contact the unit physician or on call physician. A review of the [Facility Name] Incident Report, revealed TA28 indicated that on 04/13/2023 at 5:12 PM, a resident offered R15 a brush comb. R15 then snatched the hairbrush from the resident and stood up from his/her wheelchair to fight. According to the report, TA #27 held the resident down while seated in the wheelchair while TA28 took the hairbrush from the resident. TA28 documented that the resident spit on his face. According to the report, initially, the facility planned to retrain the staff; however, on 04/14/2023, the facility reviewed video surveillance footage and suspended the staff. A review of the facility's Accident/Incident Reporting Form submitted to the state agency on 04/19/2023 as a five-day report revealed on 04/14/2023, the Administrator and Director of Nursing (DON) reviewed video footage related to a report of R15 spitting in TA #28's face. Upon reviewing the video footage from the dayroom, TA27, and TA28, used what appeared to be excessive force with R15. The investigation indicated after snatching the hairbrush, R15 attempted to stand up, and TA #27 came from behind the resident to calm them down by sitting R15 back in their wheelchair. R15 was viewed trying to punch the two [NAME], and TA27 was observed holding R15's arms at their side. According to the report, alleged physical abuse was not substantiated for TA #27; however, the facility substantiated psychological abuse on TA #28 because the TA was seen on video continuing to insight the [resident's] behavior by pointing his finger in the resident's face, and jumping at the resident which made the resident more agitated. On 02/25/2023 at 2:00 PM and 6:00 PM, and on 02/26/2023 at 5:46 PM, attempts were made to contact TA27; however, there was no answer and no option to leave a voicemail. On 02/25/2023 at 2:00 PM and 6:00 PM, and on 02/26/2023 at 5:46 PM, attempts were made to contact TA28; however, there was no answer and no option to leave a voicemail. During an interview on 04/27/2023 at 3:43 PM with Social Worker (SW) #32, he stated he had met and followed up with R15 after the incident to ensure their safety and recalled no issues. During an interview on 04/26/2023 at 1:30 PM with TA29, she stated she worked all units. The TA's duties were to sit with residents that required one-on-one observation and ensure their safety. She stated [NAME] were trained to supervise residents with behaviors, such as with R15. She said staff must redirect them and stay calm. [NAME] were allowed to prevent accidents, cue residents, and call for help, but should not restrain a resident. During an interview on 04/26/2023 at 10:48 AM with CNA14, she stated she did not witness the incident with R15 and the [NAME]. She stated staff, including [NAME], were required to stay calm and be aware of the resident's assessment and how they communicated. If a resident was agitated, staff must redirect and calm the resident and not take the resident's behavior personally. CNA14 stated staff were not permitted to force the resident or hold them down. CNA14 also stated staff were not permitted to use a raised voice, demine the resident, or point their fingers, or invade the resident's space because such behavior could be viewed as abuse. During an interview on 04/27/2023 at 8:15 AM with Licensed Practical Nurse (LPN)13, she revealed she did not witness the incident with R15; however, stated staff needed to approach R15 calmly and explain the situation. LPN13 added [NAME] were not allowed to touch the residents and were trained on proper intervention techniques. During an interview on 04/27/2023 at 3:50 PM, Therapeutic Director (TD) #31 revealed all [NAME] were trained regarding how to provide one-on-one observation, remaining at least an arms reach of the resident, not touching a resident, and most importantly, not restraining a resident in any way. He stated the [NAME] must also consider the resident's history and status, and redirect/deescalate the resident when they were having behaviors. TD31 stated the facility's expectations were to provide close monitoring and alert nursing staff if the resident's aggression continued. He stated the incident with R15 was shocking. TD31 stated neither TA27 nor TA28 had ever posed a threat to any residents and were not loud or threatening. TD31 stated he felt that in that situation, the staff were trying to get the item (brush) from the resident to prevent serious harm to residents and staff. During an interview on 04/28/2023 at 6:23 PM, the DON stated R15 was abused. The DON added she would have never expected that type of behavior, and she felt they were trying to prevent harm to R15 and the other residents. However, it was abuse and was unacceptable. The DON stated abuse would not be tolerated at the facility, and the facility had zero tolerance for any type of abuse. During an interview on 04/28/2023 at 7:35 PM, the Administrator stated it was her expectation that staff ensure resident safety and protect them from harm. She stated abuse of any type would not be tolerated. They were a zero tolerance facility. 3. A review of R2's Face Sheet revealed the facility admitted the resident on 09/30/2014 with diagnoses that included schizophrenia, schizoaffective disorder, and dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/14/2023, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident did not have physical or verbal behavioral symptoms directed toward others. The MDS indicated the resident transferred and walked independently and was independent in locomotion on the unit. According to the MDS, the resident had no functional limitations in range of motion in the upper or lower extremities. The MDS indicated the resident used a walker for mobility. A review of R2's Care Plan, revised 01/12/2023, indicated the resident had the potential for impaired adjustment and psychosocial functioning in a long-term care facility related to their diagnoses and history of behavior problems. The care plan indicated that on 01/12/2023, the resident hit another resident multiple times. Interventions directed staff to encourage the resident to notify staff when angry or dysregulated (inability of a person to control or regulate their emotional responses to provocative stimuli). The care plan indicated the resident agreed to leave area when upset. A review of R3's Face Sheet revealed the facility admitted the resident on 05/19/2009 with diagnoses that included intracranial injury with loss of consciousness, dementia with behavioral disturbance, personality change, obsessive-compulsive disorder, schizoaffective disorder, and quadriplegia. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/31/2023, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had other behavioral symptoms not directed toward others, such as verbal/vocal symptoms, like screaming and disruptive sounds, daily during the review period. The MDS indicated the resident was totally dependent on staff for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident had functional limitations in range of motion in their bilateral upper and lower extremities and used a wheelchair for mobility. Review of R3's Care Plan Report, revised 01/12/2023, revealed a problem related to behaviors and cognition. The care plan indicated the resident had behavior and mood problems related to their diagnoses and became verbally abusive toward the staff and yells out at unseen others when agitated. The care plan indicated that on 01/12/2023 the resident was struck by another resident in the day area with no injuries noted. Interventions directed staff to monitor R3 when the resident was up in the chair, alternate areas when the resident was up in the chair, and attempt one-on-one (1:1) interaction with the resident in a quiet/calm setting during periods when the resident was yelling and screaming out. A review of the [Facility Name] Incident Report, dated 01/12/2023 at 11:00 AM, revealed R3 was sitting in the day room when R2 hit R3 in the mouth. The report also indicated that another resident in the day room observed what happened and informed the nurse on the unit about the incident. R3 was assessed, and a small abrasion was noted on the resident's left upper gums. The two residents were separated, and an investigation was immediately initiated. Review of the 5-day investigation report, dated 01/17/2023, revealed that during the investigation into the incident, Medical Doctor (MD)7 and MD8 viewed video footage with the Director of Nursing (DON). It was noted that on 01/12/2023 at approximately 11:03 AM, R2 was seen yelling across the day room at R3, appearing to tell them to shut up. This was determined by reading R2's lips. The report indicated that in the video footage R2 was seen using their walker to walk over to R3 and then was seen punching R3 on the left side of their face approximately six times. The report indicated that during the investigation, R2 was asked by MD7 and MD8 about the incident, and the resident said R3 was making too much noise and kept banging on their wheelchair. R2 was apologetic and stated that they let their emotions take over their brain and stated they would never do it again. The report indicated R2 was placed on close observation every 30 minutes for seven days for aggression toward their peers. The report indicated R2 did not have a history of hitting other residents; this was an isolated incident. On 04/28/2023 at 5:50 PM, the surveyor viewed video footage of the incident described above with the DON. R2 and R3 were observed in the day room, sitting approximately 12 to 15 feet apart prior to the incident. R2 was sitting in a chair with their rolling walker positioned next to them, and R3 was sitting in a reclined geriatric chair. R2 stood up, ambulated toward R3, and R2 punched R3 six times on the left side of their face with a closed fist. Another resident (the only other person in the room) was observed to leave the day room and return approximately three minutes later with a staff member, who immediately separated R2 and R3. During an interview on 04/27/2023 at 8:58 AM, Certified Nursing Assistant (CNA)5 stated R2 could stand and walk with their walker. She said staff had to encourage R2 to get up and go to the day room and not sleep all day. She said that for the most part, R2 was usually calm and respectful. She said she was only aware of this one time that the resident lashed out and hit R3. CNA5 stated that the two residents were in the day room, and there were not any staff in the day room when the incident occurred. She said the only other person in the day room at that time was another resident, who came out of the day room and reported the incident to the staff at the nurses' station. CNA5 said she ran to the day room to see what had happened, found R2 standing over R3 with a mad face, and R3's lip was bleeding. CNA5 said she asked R2 what had happened, and R2 told her it was just too much noise because R3 liked to yell and would not be quiet, and that was why R2 hit R3. CNA5 stated R3 could not do anything for themself, required total care, and screams all day long. She said that when R3 was yelling, staff checked on the resident frequently, at least every 30 minutes, to see if the resident was okay or if they needed anything. During an interview on 04/27/2023 at 9:55 AM, Registered Nurse (RN)6 stated she recalled an incident earlier this year between R2 and R3. She said she heard a resident calling for help and when she got to the day room, CNA5 told her that R2 had hit R3. She indicated that when she entered the day room, R2 was back in their chair. RN6 stated that R3 had a slight abrasion on their gum line, but nothing that needed first aid. RN6 said R2 told her that R3 was being too loud. She said R2 had never tried to do anything like that in the past that she was aware of. She also indicated that R2 and R3 were no longer allowed to be in the day room by themselves without a staff member. RN6 said they rotated the common areas where the residents were placed because R3 was defenseless. During an interview on 04/28/2023 at 5:58 PM, the DON said she expected residents to be free from abuse and confirmed that R2, who had a BIMS score of 15 which indicated intact cognition, intentionally physically abused R3, who was defenseless. During an interview on 04/28/2023 at 7:25 PM, the Administrator said she expected residents to be free from abuse from other residents, staff, and visitors.