F0600

E

Failure to Prevent and Substantiate Resident-to-Resident Physical Abuse

Ridgeway, South Carolina Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from physical abuse in the form of resident‑to‑resident altercations. Facility records and staff interviews show that one resident with dementia and mood disorder (R66) was involved in three separate physical conflicts on the secured unit. In one incident, a CNA entered a room and observed R66 scratching another severely cognitively impaired resident (R84) on the arm, resulting in a skin tear. In a second incident, an LPN at the nurses’ station saw R66 and another moderately cognitively impaired resident (R136) trying to pass through a doorway at the same time; R66 began flailing her arms and hit the other resident with open hands, after which the other resident struck R66 in the face with her fists. In a third incident, a CNA entered a room and saw R66 and another severely cognitively impaired resident (R120) grabbing each other; R66 had scratches on her face and blood on her mouth, and the other resident had scratches on her chest.

Additional incidents involved other residents engaging in physical aggression toward one another. On one occasion, a resident with bipolar disorder (R93) approached a severely cognitively impaired resident (R125) who was seated in the dining room and struck her on the back multiple times with a closed hand. Staff witness statements documented that the striking was forceful and occurred multiple times, and progress notes recorded that the aggressor admitted to hitting the other resident and stated she understood after being told that hitting others was not acceptable. The facility’s internal investigation of this event was initially documented as unsubstantiated, despite staff accounts that the hitting occurred and that police were contacted for an incident number. The Administrator later acknowledged that this incident should have been substantiated as abuse because it happened.

Another incident involved a severely cognitively impaired wandering resident (R115) and the same moderately cognitively impaired resident (R136) on the secured Memory Support Unit. Facility investigation notes indicated that R115 repeatedly wandered into R136’s room, prompting R136 to yell for her to get out. Staff redirected the wandering resident several times, and after the last entry into the room, staff seated R115 in the dining room. R136 then came from behind and slapped R115 in the face. The care plan for R136 already identified socially inappropriate and aggressive behaviors and directed staff to provide comfort measures when such behaviors began. The Administrator stated that residents on the Memory Support Unit “fight back there a lot” and that the facility usually substantiated such allegations because they occurred, noting that some residents did not like others in their personal space. Across these events, surveyors determined that the facility failed to ensure residents were free from physical abuse by other residents.