Every finding on record at Abundant Christian Living Community Rehabilitation

Based on facility policy review, medical record review, observations, and interviews the facility failed to provide a clean and homelike environment for 1 resident (Resident #41) of 94 residents reviewed for a homelike environment. The findings include: Review of the facility's policy titled, Cleaning Assignments, dated 4/2024, revealed .maintain a neat, clean .homelike environment . Medical record review revealed Resident #41 was admitted to the facility on [DATE] Diabetes Mellitus, Need for Assistance with Personal Care, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 was cognitively intact. During an observation in room [ROOM NUMBER] on 7/7/2024 at 11:50 AM, revealed the privacy curtain for Resident #41 had a large brown stain to the left bottom corner. During an interview on 7/7/2024 at 11:52 AM, Resident #41 stated the large brown stain to the bottom corner of the privacy curtain had been present awhile and was unsure of the substance. During an observation in room [ROOM NUMBER] on 7/8/2024 at 8:10 AM, revealed the privacy curtain for Resident #41 had a large brown stain to the left bottom corner. During an interview on 7/9/2024 at 7:31 AM, the Housekeeping Director (HD) stated privacy curtains located in the resident rooms are routinely cleaned at least quarterly and when visibly soiled. The HD confirmed the privacy curtain in room [ROOM NUMBER] should have been changed due to the presence of an unknown substance on the privacy curtain and did not reflect a clean, homelike environment for Resident #41.

Based on facility policy review, medical record review, observations, and interviews the facility failed to follow the policy for restraint usage for 1 resident (Resident #65) of 5 residents reviewed for restraints. The findings include: Review of the facility's policy titled, Restraints, dated 7/2023, revealed .It is the policy of this facility that restraints only be used for the safety and well-being of the Resident(s) .Before placing a Resident in a restraint, a pre-restraining assessment must be done to determine the need .a physician's order must be obtained indicating the specific reason, type, and medical reason for restraint . Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypertension, and Muscle Weakness. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #65 had severe cognitive impairment, required total to maximum staff assistance with bed mobility and transfers. Further review revealed restraints were not used. Review of the comprehensive care plan for Resident #65 dated 6/13/2024, revealed a restraint was not in use. Medical record review revealed Resident #65 had no order for a restraint, restraint consent, assessment, or ongoing re-assessment for restraint usage. During an observation on 7/7/2024 at 12:10 PM, revealed Resident #65 was asleep in the bed with the bilateral bed bolsters (a type of restraint) in place. During an observation on 7/8/2024 at 8:30 AM, revealed Resident #65 was asleep in the bed with the bilateral bed bolsters in place. During an observation and interview on 7/8/2024 at 2:06 PM, the Assistant Director of Nursing (ADON) stated he was not aware of Resident #65 having a restraint (bolsters)placed on the bed. During an interview on 7/8/2024 at 2:15 PM, the Director of Nursing (DON) stated when restraints are used it was her expectation an initial assessment, signed consent, and a physician's order was to be obtained. The DON confirmed Resident #65 did not have an order, signed consent, or an initial assessment prior to the use of a restraint.

Based on review of facility policy, medical record review, review of video footage, review of facility investigation, and interviews, the facility failed to prevent abuse for 1 resident (#1) of 5 residents reviewed for abuse. Resident #1's family moved the resident from the facility out of fear of the psychosocial consequences from the facility's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The findings included: Review of a facility policy Abuse Protocol revised date 8/2021 revealed .Verbal Abuse: the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had unclear speech and a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired. Resident #1 required extensive assistance of 1 staff for bed mobility, dressing, and eating, and total dependance for transfers with 2 persons assisting. The resident was always incontinent of bowel and bladder. Review of a video clip dated 5/9/2022 and time stamped 11:51 AM-11:56 AM, showed Resident #1 lying in bed. Certified Nursing Assistant (CNA) #4 entered the resident's room with a mechanical lift (device used to assist in lift/transfer of a person unable to stand). CNA #3 entered the room and asked CNA #4 what are you doing with that (mechanical lift)? CNA #4 replied, I am getting her ass up because they [contractors] want to do the molding [repairs] in here. Review of the video clip dated 5/9/2022 and time stamped 11:56 AM-12:01 PM, showed Resident #1 lying in bed. CNA #3 asked CNA #4 if he was going to get Resident #1 up and out of bed. CNA #4 replied yeah, after I smoke. Gotta [got to] calm my damn nerves down. The CNAs continued a discussion about lunch being provided by the facility and if they were going to eat. CNA #3 stated .Everybody already running up there [to the lunch area]. If they don't [expletive] it up before we get there. Don't want nothing everybody else done put they hands on. CNA #4 responded You know what I think? Everybody just needs to beat the hell out of everybody else. The CNAs continued the discussion about getting Resident #1 out of bed. CNA #3 stated I was not going to do it [get Resident #1 up]. I didn't give a damn what they say. CNA #4 was observed to exit the room and closed the door behind him. Resident #1 said ma'am. CNA #3 stated Don't start ma'am me. Gonna [going to] get you up while they fix the baseboard. CNA #3 then asked Resident #1 if the remote for the television had been found. The resident shook her head no. The CNA then removed the resident's soiled brief and tossed it on the floor. The CNA's actions while caring for the resident were brisk and hurried. Review of the video clip dated 5/9/2022 and time stamped 12:01 PM-12:06 PM showed CNA #3 continued to provide care to Resident #1, without telling her what she was doing or talking to the resident. The CNA's actions while caring for the resident were brisk and hurried. CNA #3 removed the incontinence pad from underneath Resident #1 and tossed it onto the floor. The CNA placed her hand behind the resident's neck and raised Resident #1 to a sitting position, removed her hand and the resident, unable to support herself on her own, fell back onto the bed in a supine position. CNA #3 then told the resident Sit up (Resident #1 was not capable of sitting and holding herself up independently). CNA #3 placed her hand behind the resident's neck and raised the resident to a sitting position again. The CNA again told the resident Sit up we gotta [got to] put clothes on you and the CNA again removed her hand from behind the resident's neck and Resident #1, unable to support herself, fell back onto the bed. CNA #3 then grabbed the resident's left arm and pulled the resident to a seated position. CNA #3 then pulled the resident's t-shirt off her left arm, over the resident's head, and unsupported by CNA #3, fell back onto the bed. The CNA then pulled the t-shirt off the resident's right arm. The CNA continued to dress the resident without talking or acknowledging her and leaving her naked body exposed. CNA #4 reentered the room, and the CNAs rolled the resident and placed a lift pad underneath her. CNA #4 stated I was so damn mad yesterday. When asked why by CNA #3 he replied, I'm just sick of this [expletive]. Review of the video clip dated 5/9/2022 time stamped 12:06 PM-12:11 PM, showed CNA #4 told Resident #1 I tell you right now when you get in that chair you are gonna [going to] sit still. The resident made an inaudible comment to CNA #4 and CNA #3 asked him what the resident had said. CNA #4 stated She asked how long she would be there [sitting in the chair]. He responded by saying he did not know. CNA #4 told the resident If you[OBSCENITY]in that [chair] that's where you will be all day long. Good luck. The mechanical lift battery did not work, and CNA #4 stated Give me that damn battery and he exited the room. Review of the video clip dated 5/9/2022 and time stamped 12:11 PM-12:16 PM, showed while CNA #3 and CNA #4 assisted Resident #1 from her bed to her wheelchair with the use of a mechanical lift, CNA #4 was watching television and stated, Let's see how this[OBSCENITY]works. Resident #1 said something which was inaudible. CNA #4 stated Yeah, we will cover you up then CNA #4 said Check this[OBSCENITY]out while watching the television. Resident #1 then stated ma'am, ma'am. CNA #4 replied to the resident No, No, quit [resident name]. CNA #3 then stated Wait a minute [resident name], can we get you in here [chair] and get this right? Put your feet back down. What are you doing? CNA #4 then yelled Quit, quit, stop, stop, stop, stop, stop, stop. CNA #3 told Resident #1 We are straightening you up just give us time. CNA #3 then asked CNA #4 if they were going to lean the resident back in her wheelchair. CNA #4 stated No, I ain't gonna lay her back. CNA #4 walked around in front of the resident's wheelchair and stated, Don't look at me like I'm crazy. He then reclined the wheelchair and rolled Resident #1 out of the room. Review of a facility reported investigation dated 5/19/2022, showed the Administrator was notified by Resident #1's Medicaid Case Manager of a request to transfer Resident #1 to a different Long-Term Care facility, without providing the reason for the request. The Administrator and the Director of Nursing (DON) called Resident #1's mother and asked the reason for the request to transfer Resident #1. Resident #1's mother stated her son had placed a hidden video camera in Resident #1's room and the video showed 2 CNAs being verbally abusive to the resident. The resident's mother refused to provide the video to the facility until the resident was transferred out of the facility on 5/20/2022. Telephone interview with Resident #1's mother on 6/6/2022 at 4:50 PM, confirmed she watched the video of the 2 CNAs. The mother stated the CNAs were being mean to Resident #1 and she reported it to the Administrator and Director of Nursing (DON) when they called her. Telephone interview with Resident #1's brother on 6/6/2022 at 5:05 PM, revealed he had placed the camera in Resident #1's room on 5/8/2022 because the family had noticed some changes in the resident and were concerned about the care she was receiving. Interview with the Physical Therapist on 6/13/2022 at 12:15 PM, confirmed she worked with Resident #1 for contractures of her hands and ankles. She stated she also worked with Resident #1 on sitting balance and the resident always required minimum to moderate assistance to maintain a seated position. Telephone interview with the Psychiatric Nurse Practitioner (NP) on 6/13/2022 at 4:15 PM, revealed Resident #1 was difficult to understand, but was mentally able to engage in conversation. During interview and review of the video clips with the Corporate Compliance Officer, the Administrator, and the DON on 6/13/2022 at 3:00 PM, they stated CNA #3 and CNA #4 used inappropriate language when providing care for Resident #1, CNA #3 should have supported the resident when providing care, and CNA #3 should not have allowed the resident to just fall back on the bed unsupported.

Based on review of facility policy, medical record review, review of video footage, review of facility investigation and interview the facility failed to ensure a sanitary environment to prevent transmission of infection or disease for 1 resident (#1) of 5 sampled residents. The findings included: Review of the facility policy General Policies revised 1/2021 revealed .b. Maintain a sanitary environment for personnel, Residents, visitors, and the general public . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating Resident #1 was moderately cognitively impaired. The resident required extensive assistance for bed mobility, dressing, and eating The resident was always incontinent of bowel and bladder. Review of the video footage dated 5/9/2022 and time stamped 11:56 AM-12:01 PM, showed Resident #1 lying in bed. Certified Nurse Assistant (CNA) #3 removed the resident's soiled brief and tossed it on the floor. Review of the video clip dated 5/9/2022 and time stamped 12:01 PM-12:06 PM, showed CNA #3 continued to provide care for Resident #1 and removed the incontinence pad from underneath Resident #1 and tossed it onto the floor. Review of the video clip dated 5/9/2022 and time stamped 12:11 PM-12:16 PM, showed CNA #3 removed Resident #1's bed linens and tossed them on the floor, along with the soiled brief and incontinence pad. Observation of the video footage showed the CNA then picked all of the items up with ungloved hands and took them out of the view of the camera. Review of a facility reported investigation dated 5/19/2022 showed Resident #1's mother stated her son had placed a hidden video camera in Resident #1's room. Interview and review of the video clips with the Corporate Compliance Officer, the Administrator, and the Director of Nursing confirmed CNA #3 should have placed soiled briefs and linens in a plastic bag and worn gloves when handling the soiled items.

Based on facility policy review, medical record review, observation, and interview, the facility failed to honor the right to self-determination related to resident choices for food preferences for 1 resident (Resident #25) of 12 residents reviewed for choices. The findings include: Review of the facility policy titled, Menu Substitutions and Alternatives, dated 2/14/2019, showed .Resident .who express a refusal of the food served are offered a substitute of similar nutritive value .Nursing Services offers the substitute in a timely manner when a resident refuses a menu item . Medical record review showed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's comprehensive care plan dated 2/2/2021, showed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed .Staff to honor food and fluids preferences as able . Review of Resident # 25's physician's order dated 2/11/2021, showed .NSOT [no salt on tray] Diet- Regular Texture- Thin Liquids .add fortified foods with all meals (help meet est [estimated] needs) . Review of Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. She required set up assist with meals, she had no weight loss, and received a therapeutic diet. Observation on 10/4/2021 at 12:42 PM, showed Resident #25's lunch tray was delivered by Certified Nursing Assistant (CNA) #1. CNA #1 entered the resident's room and set up the resident's lunch tray. Resident #25 stated to CNA #1 that she did not like anything on her lunch tray. CNA #1 stated, what about your orange cake and the resident stated to the CNA, it does not look good to me. The CNA stated what about your broccoli .I don't want it and the resident stated back to her I get broccoli every day. CNA #1 exited the room without offering the resident a substitute. During an interview on 10/4/2021 at 12:44 PM, Resident #25 stated she did not like the food on her tray. The resident stated she told CNA #1 she did not like the food and was not offered a substitute by the CNA. Resident #25 stated she would like to have a cold plate with cottage cheese. During an interview on 10/4/2021 at 12:47 PM, the Director of Nursing (DON) stated it was her expectation for residents to be offered a substitute if they do not like what was served on their tray.

Based on review of facility policy, medical record review, and interview the facility failed to provide transportation services for a scheduled medical appointment for 1 resident (#1) of 3 residents (#2 and #3) reviewed for transportation services. The findings include: Review of the facility policy titled, Transportation date reviewed 5/2008, showed .Should it become necessary to transport the Resident to .service outside the facility, arrangements for the service will be made by our facility .The Social Services Director shall have the responsibility for making arrangements for transportation . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of hospital discharge orders from a local hospital dated 8/26/2020 showed .PATIENT NEEDS UROLOGY FOLLOW UP IN 2 WEEKS . Review of a facility appointment calendar book showed Resident #1 had an appointment scheduled with a urologist on 9/9/2020 at 8:15 AM. During an interview on 11/3/2020 at 1:38 PM, the Director of Nursing (DON) stated Resident #1 had a scheduled urologist appointment on 9/9/2020 and Social Service is responsible for scheduling transportation services. The DON confirmed transportation had not been arranged for Resident #1. During an interview on 11/3/2020 at 1:55 PM, the Social Worker stated she is responsible for arranging transportation services for residents who have appointments scheduled. Resident #1 had an appointment scheduled with a urologist on 9/9/2020, the appointment was written in the appointment calendar book located at the nurse's station. Continued interview confirmed transportation services were not arranged for Resident #1. During an interview on 11/3/2020 at 2:10 PM, the Administrator confirmed the facility failed to provide transportation services to a urology appointment for Resident #1 on 9/9/2020.

Based on facility policy review, medical record review, and interview the facility failed to ensure Physician Orders for Scope of Treatment (POST) forms were completed for 1 resident (#47) of 16 sampled residents. The findings include: Review of the facility policy, Code/No Code, reviewed 1/2019 revealed .Complete a Physician Orders for Scope of Treatment .attending physician should review and a healthcare professional should initial POST . Review of the POS [REDACTED].POST must be signed by a physician . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record Review of the POS [REDACTED]. Continued review revealed the Physician had not signed or dated the form for Resident #47. Interview with the Director of Nursing on 6/12/19 at 8:44 AM, in the conference room, confirmed the Physician failed to sign the POST form for Resident #47.

Based on medical record review and interview, the facility failed to develop a Comprehensive Care Plan to include predetermined resuscitation status for 1 resident (#47) of 16 sampled residents. The findings include: Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed no resuscitation status had been included in the Comprehensive Care Plan dated 4/12/19 for Resident #47. Interview with the Director of Nursing on 6/12/19 at 8:44 AM, in the conference room, revealed the facility failed to develop a Comprehensive Care Plan to include the resuscitation status for Resident #47.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow Physician's Orders for tube feeding for 1 resident (#19) of 5 residents reviewed for tube feeding of 16 sampled residents. The findings include: Review of the facility policy .Tube Feeding . revised date 1/2019, revealed .A resident who is fed by enteral means receives appropriate treatment and services . Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Dietitian Communication/Physician's Order dated 5/8/19 revealed .D/C ( discontinue) current tube feed order .new order glucerna (type of tube feeding) 1.5 at 75 ml (milliters) hour with 40 ml flush . Medical record review of a Dietitian Communication/Physician's Order dated 5/15/19 revealed .increase tube feed order to glucerna 1.5 at 80 ml hour with 40 ml flush . Observation of the resident on 6/10/19 at 10:15 AM, in the resident's room, revealed the resident's tube feeding was infusing at 75 ml per hour. Further observation of Resident #19 on 6/11/19 at 3:12 PM revealed the resident's tube feeding was infusing at 75 ml per hour. Interview and observation with Charge Nurse #1 on 6/11/19 at 3:15 PM, in the resident room, revealed the rate of the tube feeding was infusing at 75 ml with a 39 ml flush rate. Continued interview revealed the resident's tube feeding pump had been changed out (replaced) over the weekend and the rate should have been set at 80 ml per hour with a 40 ml flush as the order stated. Interview with Charge Nurse #2 on 6/12/19 at 8:28 AM, by phone, revealed the resident's tube feeding pump was changed out 6/8/19, and the Charge Nurse confirmed the tube feeding rate was incorrectly entered when the pump was changed out. Interview and medical record review with the Registered Dietician on 6/12/19 at 8:37 AM, in the Administrators office, revealed the resident's revealed the resident's incorrect rate of 75 ml per hour from 80 ml per hour from 6/8/19 to 6/12/19 would not be a substantial amount to influence the resident's overall weight. Interview with the Director of Nursing on 6/12/19 at 10:55 AM, in the conference room, confirmed the tube feeding rate was to be 80 ml hour, and the facility's policy for tube feeding had not been followed.

Based on facility policy review, medical record review, facility records review, and interview, the facility failed to report an allegation of misappropriation for 1 resident's (#183) monies to the Department of Health Incident Reporting System (IRS) in the required timeframe. The findings included: Review of the facility Abuse policy, undated, revealed Misappropriation .the Department of Health will be immediately notified of the alleged event by the Administrator .HOW QUICKLY MUST YOU REPORT? .2. Within 24 hours (if there is not serious bodily injury) after forming your reasonable suspicion . Medical record review revealed Resident #183 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was re-admitted to the facility on [DATE], following a 6 day stay in the hospital. Review of the facility's Incident file, pertaining to the allegation of misappropriation of monies for Resident #183, revealed the resident had disclosed a theft in the morning of Thursday 11/29/17, to the wound care nurse. Continued review revealed the resident was interviewed by the Administrative Assistant, the Director of Nursing and the Social Service Director on 11/29/17 and reasonable suspicion the theft had occurred was established. Further review revealed the facility reported the incident to the Department of Health on Tuesday, 12/6/17, a delay of 6 days. Interview with the Administrator on 7/11/18 at 3:35 PM, in the conference room, confirmed the required timeframe for reporting had not been met.

Based on medical record review, observation and interview, the facility failed to include 1 resident's (#182) specific care needs in the Baseline Admission Care Plan of 3 residents reviewed for baseline care plans. The findings included: Medical record review revealed Resident #182 was admitted to the facility on [DATE] with [MEDICAL CONDITION] requiring Blood Transfusion, Adult Failure to Thrive, Gastrostomy Tube, [MEDICAL CONDITION] and End Stage [MEDICAL CONDITION]. Further review revealed the nursing Admission Evaluation, dated 6/6/18, .Right subclavical Ash Cath ([MEDICAL TREATMENT] access central line catheter (CVC)) .Shunt in Left Arm A-V (arterio-venous) fistula . Medical record review of the Physician's History and Physical dated 6/16/18 revealed .UGI (upper gastrointestinal) Bleed - secondary to Gastritis (inflammation of the lining of the stomach) .vomited blood clots .received 2 units of blood . Review of an interval physician's orders [REDACTED].seen for fall overnight .fell out of bed .Sent to ED (emergency department) .found to have fractured clavicle R (right) . Medical record review of the Baseline Admission Care Plan revealed the following: The resident's 2 [MEDICAL TREATMENT] were not care planned; The resident's weight and plan for weight maintenance was not entered in the provided area; The resident's fall and clavicle fracture was not included; A tube feeding was listed, the rate and hours of administration were not included; The presence of a [DEVICE] was not care planned; and the provided area for .risk for abnormal bleeding or hemorrhage . was left blank, no history of the recent UGI bleeding was care planned. Interview with the supervising Registered Nurse (RN) #1 7/12/18 at 10:10 AM, at the 500 hall nursing station, confirmed the Baseline Care Plan had not included all of the resident's (#182) care needs.

Based on facility policy review, medical record review and interview the facility failed to revise the comprehensive care plan related to an indwelling urinary catheter for 1 Resident (#2) of 5 sampled residents reviewed with a catheter and failed to involve 2 Residents (#2, #55) and the resident's representative(s) in the care planning conferences of 12 residents interviewed. The findings included: Review of the facility policy, MDS/RAI/Care Planning, undated, revealed .The resident will .be assessed at least quarterly and care plan reviewed by the interdisciplinary team .and more often if required .The Interdisciplinary Team Members are responsible for completing .Care Plan for all existing problems . Review of the facility policy Interdisciplinary Care Conference Guidelines undated revealed .Goal: To develop a meaningful plan of care that meets the individual needs of the resident in order to provide effective and person-centered care and the components that are necessary for the quality of life .Initial Care Plan Conference: within 21 days of admission .every 90 days thereafter .The Social Service Director will take on responsibility and accountability for the care conference .The Social Services Director will schedule .residents to be discussed at care conference . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact, had oxygen therapy, a ventilator (a machine that mechanically assists a patient in breathing) and [MEDICAL CONDITION] care. Further review revealed the resident had an indwelling catheter. Medical record review of Resident #2's care plan dated 5/30/18 revealed the following problems .(indwelling urinary catheter) d/c (discontinued) 2/18/17 . Review of Resident #2's Physician Recapitulation orders dated 5/30/18 revealed (indwelling urinary catheter) 18 French (size of catheter) 10 cc (cubic centimeter) . Interview with Resident #2 on 07/10/18 at 8:32 AM, in the resident's room, revealed she had not been invited to attend or participate in a care plan conference to discuss her plan of care. Interview with the Social Service Director on 7/11/18 at 4:23 PM, in the conference room, confirmed Resident #2 and the resident's representative had not been included in a care plan conference since admission on 12/16/16. Interview with MDS Coordinator #1 on 7/12/18 at 9:30 AM, in the conference room, confirmed Resident #2's comprehensive care plan had not been revised to reflect the resident had an indwelling urinary catheter. Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had moderate cognitive impairment. Continued review revealed the resident required 2 person assistance with bed mobility, transfers, and toileting. Interview with Resident #55 on 7/10/18 at 8:58 AM, in the resident's room, revealed she had not been invited to any meetings to discuss her plan of care. Interview with the Social Service Director on 7/12/18 at 1:14 PM, in the conference room, revealed Resident #55 and a resident representative had not been invited to attend or participate in a care plan conference since admission on 2/2/18.

Based on facility policy review, medical record review, observation and interview the facility failed to provide [MEDICAL TREATMENT] care as defined in the facility's [MEDICAL TREATMENT] Care Guidelines for 1 resident (#182) of 2 residents reviewed for [MEDICAL TREATMENT]. The findings included: Review of the facility's policy, [MEDICAL TREATMENT] Care, revised 1/2004, revealed .Guidelines .All residents receiving [MEDICAL TREATMENT] treatment will have their access site assessed every shift and documented on the MAR (Medication Administration Record). Assessment includes the following .For Peripheral access .Check bruit and thrill. For Central access .Check any port cap/clamp is taped .No blood pressure or venipuncture will be done in the arm with the graft/fistula . Further review revealed there were 10 care guidelines defined and also instructions to use a [MEDICAL TREATMENT] Flow Sheet for each [MEDICAL TREATMENT] patient. Continued review revealed the policy included a template of the Flow Sheet and instructions for documentation in the 16 provided columns of the [MEDICAL TREATMENT] Flow Sheet. Medical record review revealed Resident #182 was admitted to the facility on [DATE] with [MEDICAL CONDITION], Adult Failure to Thrive, [MEDICAL CONDITION] and End Stage [MEDICAL CONDITION]. Further review revealed the nursing Admission Evaluation, dated 6/6/18, .Right subclavical Ash Cath ([MEDICAL TREATMENT] access central line catheter (CVC)) .Shunt in Left Arm A-V (arterio-venous) fistula . Observation and interview with Resident #182 on 7/9/18 at 10:48 AM, revealed the resident was not going to the scheduled Monday [MEDICAL TREATMENT] (HD) due to her brother-in-law's death. She stated her HD treatment would be done Tuesday. Observation included an intact dressing to a right upper chest. Continued observation revealed no signage in the room indicating blood pressure and venipuncture were not to be performed in the left arm. Interview with Licensed Practical Nurse (LPN) #2 at 9:40 AM, on 7/12/18, at the medication cart, with concurrent review of Resident #182's electronic MAR and Treatment Administration Record (TAR) confirmed there were no entries provided to assess and document the [MEDICAL TREATMENT] access as required in the [MEDICAL TREATMENT] Care guidelines. Further interview revealed LPN #2 was not aware the resident had the internal A-V fistula. Interview with the supervising Registered Nurse (RN) #1 on 7/12/18 at 11:30 AM, in the conference room, revealed .what is the date on that (a reference to the [MEDICAL TREATMENT] Flowsheet) .as long as I have worked I haven't seen that used . Further interview confirmed the requirements for care of the [MEDICAL TREATMENT] resident in the facility's [MEDICAL TREATMENT] Care Guidelines and Flow Sheet had not been provided for Resident #182.

Based on medical record review, observation, and interview, the facility failed to provide pharmaceutical services for 1 (#43) of 2 residents observed for medication administration. The findings included: Medical record review of a physician's orders [REDACTED].#43, revealed .[MEDICATION NAME] (antidepressant medication) 5 mg (milligrams) Q (every) day. Observation and interview on 7/10/18 at 7:50 AM, revealed Licensed Practical Nurse (LPN) #6 preparing scheduled medications for Resident #43. Interview with LPN #6, at the time of the observation, at the medication cart on the 500 hallway, revealed there was no [MEDICATION NAME] available for administration in the resident's medication supply. Continued observation revealed LPN #6 went to the nursing station and contacted the pharmacy. Interview with LPN #6, on 7/10/18 at 7:58 AM, at the nursing station, revealed the pharmacy told LPN #6 the prescription for the [MEDICATION NAME], ordered on [DATE], had never been received by the pharmacy and confirmed the medication had not been supplied for administration to the resident.

Based on observation and interview the facility failed to ensure expired biologicals were discarded in 1 of 2 medication storage rooms. The findings included: Observation with Registered Nurse (RN) #1 on [DATE] at 1:05 PM, in the upper level medication storage room, revealed 26 blue top laboratory tubes 3 ml (milliliter) with an expiration date of [DATE] available for resident use. Interview with RN #1 on [DATE] at 1:20 PM, in the upper level medication storage room, revealed the blue top tubes were used to obtain blood for PT/INR (a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder) levels. Further interview confirmed there were 26 blue top laboratory tubes with an expiration date of [DATE] available for resident use. Continued interview revealed the tubes were to be discarded after the expiration date.

Based on medical record review, observation, and interview, the facility failed to maintain an accurate medical record for 1 (#43) resident of 33 residents reviewed. The findings included: Medical record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].#43 revealed .[MEDICATION NAME] (antidepressant medication) 5 mg (milligrams) Q (every) day. Observation and interview on 7/10/18 at 7:50 AM revealed Licensed Practical Nurse (LPN) #6 preparing scheduled medications for Resident #43. Interview with LPN #6, at the time of the observation, at the medication cart on the 500 hallway, revealed there was no [MEDICATION NAME] available for administration in the resident's medication supply. Continued observation revealed LPN #6 went to the nursing station and contacted pharmacy. Interview with LPN #6, on 7/10/18 at 7:58 AM, revealed the pharmacy told LPN #6 the prescription for the [MEDICATION NAME], ordered on [DATE], had never been received by the pharmacy and confirmed the medication had not been supplied for administration to the resident. Observation and interview with LPN #6, on 7/10/18 at 8:05 AM, of the electronic Medication Record for (MONTH) (YEAR), on the medication cart, on the 500 hallway, revealed LPN #6 had documented Resident #43 had received the [MEDICATION NAME] on 7/2/18, 7/3/18, 7/6/18, and 7/9/18, and confirmed the [MEDICATION NAME] was not administered as documented.

Based on review of facility policy, medical record review, observation and interview, the facility failed to assess for the use of a concave mattress and side rails as restraining devices for one resident (#103) of 3 residents reviewed for physical restraints, of 25 sampled residents. The findings included: Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy, Physical Restraints, revealed .physical restraints include but are not limited to the use of such devices as .side rails .that the resident cannot easily remove . Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating the resident was severely cognitively impaired. Continued review of the MDS revealed no documentation side rails were in use. Observation on 5/17/16 at 11:30 AM, in the resident's room, revealed the resident lying in the bed on a concave mattress with all 4 side rails raised. Observation on 5/17/16 at 3:05 PM, in the resident's room, revealed the resident lying in the bed on a concave mattress with all 4 side rails raised. Observation on 5/18/16 at 7:35 AM, in the resident's room, revealed the resident lying in the bed on a concave mattress with all 4 side rails raised. Interview with Certified Nurse Assistant (CNA) #1 on 5/18/16 at 8:00 AM, outside of the resident's room revealed, .(Resident #103) can't get up by himself, his legs don't function well. I'm not sure why the side rails are used . Interview with Registered Nurse (RN) #1 House Supervisor on 5/18/16 at 8:15 AM, at the upper level nurse's station, revealed .All 4 rails are not supposed to be up, we will put them up if the family requests it. Two half rails are used because he rolls; it keeps him from rolling out of bed. The rails are used to hold the concave mattress in place . Interview with MDS Coordinator #1 and MDS Coordinator #2 on 5/18/16 at 8:30 AM, in the MDS office, confirmed the facility failed to properly assess for the use of side rails and a concave mattress on the quarterly MDS dated [DATE].

Based on observation and interview, the facility failed to make the most recent survey results available to the public and the residents in the facility. The findings included: Observation on 8/17/15 at 10:17 AM, on the first floor next to the elevator revealed a survey notebook in a slot compartment. Further observation revealed survey results from 5/22/13 in the notebook. Interview with Administrator on 8/17/15 at 11:08 AM, on the first floor next to the elevator confirmed These are not the most recent survey results. The last survey was done in 2014. These are 2013 survey results in this notebook.

Based on facility policy review, medical record review, and interview, the facility failed to complete discharge summaries for 22 residents discharged home or to other nusing facilities of 30 residents reviewed in the admission sample. The findings included: Review of facility policy, Admission, Transfer and Discharge, no date revealed .When a resident is discharged , a brief description of the significant finding and events of the residents stay in the nursing home, the condition on discharge and the recommendation and arrangement for future care, if any, shall be provided. Interview with the Medical Records Clerk on 8/17/15 at 2:00 PM, in the conference room confirmed We use to do discharge summaries but no discharge summaries were completed for the listed residents. Interview with the Administrator on 8/17/15 at 2:15 PM, in her office confirmed the facility failed to complete discharge summaries for 22 residents with anticipated dischargesd residents per facility policy.

Based on medical record review, observation, and interview, the facility failed to provide an order for [REDACTED]. The findings included: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review on 8/17/15 revealed no order for placement of a urinary catheter. Observation on 8/17/15 at 12:21 PM, in Resident #41 room revealed the resident asleep in her bed with the urinary catheter tube visible and the urinary bag placed in a privacy bag on the right side of the bed. Interview with LPN #1 on 8/17/15 at 2:20 PM, at the ground floor nursing station revealed Resident #41 currently had a urinary catheter. Interview with Director of Nursing on 08/18/2015 at 4:33 PM, in the conference room confirmed The nurse practitioner placed the urinary catheter on 7/7/15 but did not write an order for [REDACTED].>

Based on medical record review, review of the facility timeline and investigation, review of facility policy, review of employee time cards, review of a facility surveillance video, and interview the facility failed to protect two Residents (#1 and #2) with Dementia from physical and mental abuse of five Residents reviewed. The facility failed to stop abuse immediately and report the witnessed abuse after Resident #1 was abused, allowing three alleged perpetrators, Certified Nursing Assistants (#2, #3, and #4), to continue to abuse Resident #1 and Resident #2. The facility's failure placed all Residents with Dementia in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a Resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on January 30, 2012, at 4:00 p.m. The Immediate Jeopardy was effective January 14, 2012 and is ongoing. A partial extended survey was conducted on January 31, 2012. Substandard Quality of Care was cited under tag F-223 at a scope and severity level of a "J". The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of 30-day Minimum Data Set (MDS) dated [DATE], revealed the Resident scored eight on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition; had no depressive symptoms; had no behavior symptoms; required extensive assistance with all activities of daily living (ADL) except eating, which required supervision; and used a manual wheelchair for mobility. Continued review of a 60-day MDS dated [DATE], revealed the Resident scored three on the BIMS, indicating severely impaired cognition; scored six on the Mood Interview, indicating Depression; had difficulty focusing attention and had disorganized thinking; required extensive assistance with all ADLs, to include eating; and used a manual wheelchair for mobility. Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a MDS dated [DATE], and January 1, 2012, revealed the Resident had short and long-term memory problems, had severely impaired cognitive skills for daily decision making; had no depressive or behavior symptoms; required extensive assistance to total dependence with all activities of daily living (ADL); and used a manual wheelchair for mobility. Review of a facility timeline and investigation dated January 19, 2012, revealed on January 14, 2012, Certified Nursing Assistant (CNA) #1 reported to Registered Nurse (RN) #1 that CNA's #2, #3, and #4 sprayed (Resident #1) with water. Continued review of the timeline dated January 19, 2012, revealed the following: January 14, 2012, "Around 4:00 a.m., (CNA #1) reported to (RN #1) that (CNA's #2, #3, and #4) went together in the mornings to spray (Resident #1) with water while (Resident) was asleep. (RN #1) immediately checked (Resident #1). As (RN #1) approached (Resident's) room...(CNA's #2 and #5) were coming out of (Resident's) room...(RN #1) entered (Resident's) room followed by (CNA's #3 and #8). (Resident's) gown and face were wet. (RN #1) asked the CNA's why (Resident) was wet, and both CNA's (#3, #8) claimed not to know." January 15, 2012, at 4:45 p.m., RN #1 "advised the Director of Nursing (DON) of the allegations of abuse...at 9:03 p.m., the DON called the Administrator about the abuse allegations. (CNA's #2, #3, and #4) were not scheduled to work." January 17, 2012, the Administrator and DON met with CNA #2 to discuss the allegations and the CNA made a partial admission. CNA's #2, #3, and #4 were suspended without pay pending the investigation results and on January 20, 2012, were terminated from employment for the "treatment" of Resident #1. January 22, 2012, CNA's #5 and #8 are terminated for providing misleading information during the investigation. Continued review of the investigation findings dated January 19, 2012 , revealed, "(CNA's #2, #3, and #4) worked together on the top floor of (facility's) healthcare center on the nightshift. Sometime in December (2011), (CNA #2) asked (CNA's #3 and #4), 'what would happen if we sprayed (Resident #1) with water?' All of them (CNA's #2, #3, and #4) thought (Resident's) reaction would be comical. (Resident #1) suffers from Dementia...(Resident #1) has a private room. (Resident #1's) room shares a bathroom with (Resident #2's) private room. The bathroom is between (Resident #1's) and (Resident #2's) rooms. Around 4:00 a.m., the CNA's (#2, #3, and #4) entered (Resident #2's) room and went to the bathroom. (CNA #2) filled the syringe with tap water. They (#2, #3, and #4) opened the door between the bathroom and (Resident #1's) room. While standing in the bathroom behind the threshold, (CNA #2) sprayed water on the light fixture and ceiling above (Resident #1). The water then dripped down onto (Resident #1's) shoulder. (Resident #1) woke up and pulled (Resident's) covers up over (Resident's) wet shoulder and went to sleep. The CNA's (#2, #3, and #4) laughed. Together, they (#2, #3, and #4) continued to visit (Resident #1's) room at approximately 4:00 in the morning to spray (Resident #1). By the third visit, they started spraying (Resident) directly. They targeted exposed areas...such as...head, face, and hands. They took turns squirting (Resident #1)...(Resident #1) woke up during these episodes and swore using all types of vulgarities. (Resident #1) would yell at (Resident's spouse's name) and tell spouse to "stop pissing" on (Resident). After using tap water...they decided to use cold water. They collected water from the bottom of ice coolers on the floor. At first they sprayed cold water above the bed and let it drip on (Resident). Later, they sprayed (Resident) directly. Again, they sprayed any exposed areas...usually...face and hands. All three of them took turns spraying (Resident) with the cold water. (Resident) woke up and swore and always blamed (Resident's spouse) during the rant. Next, they decided to use toilet water...(CNA's #2, #3, and #4) each filled the syringe with toilet water and sprayed it onto (Resident). They also squirted (Resident #2) at least twice. Because (Resident #2) did not react, they did not persist in spraying (Resident #2)...Several photographs were taken of (Resident #1). The first photograph was taken by (CNA #3). (Resident #1) was getting into bed with (Resident #2). (CNA #3) thought it was cute. (Resident #1's) buttocks were exposed and (CNA #3) took a picture with (CNA #3's) cell phone. (CNA #3) showed (CNA #2) the photograph. (CNA #2) asked (CNA #3) to forward the photograph to (CNA #2)...so (CNA #2) could send it to (CNA #2's sibling) who works at a local hospital...(CNA #3) forward the picture, and (CNA #2) sent it to (CNA #2's sibling)...Both (CNA #2 and #3) report the picture has been deleted from their phones. On another occasion, (CNA #2) showed a picture of a Resident's (no name) buttock's with a pad underneath covered with feces to (CNA #7). The CNA asked why (CNA #2) was taking pictures of a Resident. (CNA #2) replied...sent it to (CNA #2's sibling) to show (sibling) what they dealt with every night. This photograph was taken around Christmas. According to (CNA #2) all of the photos have been deleted from (CNA #2's) phone...One evening the CNA's made a video of (Resident #1) while (Resident) was in an agitated state. (Resident) sat up on the edge of (Resident's) bed...breasts were exposed and they showed the video to other CNA's on the floor. The CNA's report the video has been deleted." Review of a written statement (no date), by RN #1 revealed, "On January 14, 2012, CNA #1 informed me of the mistreatment of [REDACTED].#2, #4, and #3 would squirt cold water on (Resident) every morning around 4 am (4:00 a.m.) in attempt to wake (Resident) and agitate (Resident) so (Resident) would start cursing...one occurrence CNA #2 squirted (Resident) w/toilet (with toilet) water...the 3 (three) CNA's would enter the bathroom through (Resident #2's) room as to not be noticed since both (Resident #2's) room and (Resident #1's) room share one bathroom. They thought it was funny when (Resident #1 started yelling and cursing...this happened each time the shift worked except when (Resident #1) had PNA (Pneumonia)...said that (CNA #2) had even recorded an incident of this on (CNA #2's) cell phone...After (CNA #1) reported this to me I went upstairs to observe the CNA's...approximately 4:40 a.m...I looked down Resident #1's hallway and saw (CNA #2) and a CNA...I think CNA's name is (CNA #5)...coming out of (Resident #2's) room...they (CNA's #2, #5) had just made it to the end of the hall when I heard (Resident #1's) sentry alarm sound...(CNA's #4 and #8) walked into (Resident #1's) room and I followed them. (Resident #1) was laying in bed moving around and saying something like, 'I'm trying to get the water out.' I looked at the head of...bed...was wet around (Resident #1's) pillow. I then asked the CNA's (#4, #8) in the room why (Resident #1's) pillow and around it was wet. They replied, 'Oh (Resident #1) does that sometimes. Then I looked on the wall above (Resident #1's) head and the wall was covered with water. I asked the CNA's why (Resident #1's) wall was wet and has somebody been squirting water on (Resident #1). They didn't respond but just looked toward the floor and shrugged their shoulders. I then spoke with other staff member on my rotation and they also reported inappropriate behavior they had noticed from (CNA #2)...Addendum to statement given regarding (Resident #1) and morning of January 14, 2012...Our shift was scheduled to be off Saturday night January 14, 2012, and Sunday night January 15, 2012. I then notified the DON on Sunday evening January 15, 2012." Review of a written statement dated January 16, 2012, by CNA #3 revealed (CNA #3) denied knowledge or involvement in any Resident abuse. "...I try to treat every Resident as if they were family...We work as a team...I do my job to the best of my ability, and that does not include being a part of Resident abuse." Review of a written statement dated January 16, 2012, by CNA #4 revealed (CNA #4) denied witnessing or involvement in any type of Resident abuse. "...all rounds and call lights are answered as a team...I treat every Resident with respect and as if it were me, how I would want to be treated." Review of a facility email dated January 16, 2012, at 11:23 a.m., from the Administrator to the Human Resources Director, revealed the Administrator had received a call from CNA #1 on the morning of January 16, 2012. CNA #1 informed the Administrator that sometime after December 20, 2011, CNA #1 witnessed CNA #2 get a syringe from a Licensed Practical Nurse (LPN), and CNAs #1, #3, #4, and #6 witnessed CNA #2 use ice water and toilet water from a commode to squirt one of the Residents (no Resident named). CNA #1 revealed to have reported the abusive actions to RN #1 on or about January 13, 2012. When CNA #1 was asked by the Administrator why CNA #1 did not stop the abuse and report the abuse immediately, CNA #1 revealed was afraid of CNA #2. Review of a facility email dated January 16, 2012, at 11:35 a.m., from CNA #1 to the Administrator, revealed the statement was in reference to an alleged abuse which occurred "late December 2011 or early January 2012." CNA #1 alleged CNA #2 obtained a saline flush syringe from an LPN, and used ice water from a cooler and water from a toilet to squirt a Resident (no resident(s) named). CNA #1 revealed did not remember precisely when it was done, but did reveal to "think this was probably the first or second week in January but (CNA #1) could not remember precisely." CNA #1 revealed the abuse was witnessed along with another new coworker and revealed, "...Because of threatening comments made by CNA #2, CNA #1 was fearful for (CNA#1's) personal safety and home..." Continued review of the emailed statement revealed the next week (handwritten date indicated January 14, 2012) CNA #1 reported the alleged abuse to RN #1, as witnessed by CNA #1. Review of a written statement (no date), by CNA #6 revealed Resident #1 "has been getting aggravated up in the morning hours by CNA's #3, #2, and #4...syringes are being used by squirting water on (Resident)..." Review of a written statement (no date), by CNA #7 revealed "(CNA #2) approached me while I was on break...wanted to show me a picture on (CNA's) cell phone...the picture was of a Resident's (no name) bare butt and on the pad was feces. I asked why...took that picture...CNA #2 replied, 'I text it to my (sibling) to show...what we go through at night.'" Review of a typed, unsigned statement dated January 17, 2012, titled "Meeting with (CNA #2)" revealed, "(DON) present along with myself...(Administrator)...(CNA #2) ...to the facility at 7am (7:00 a.m.) to meet with (DON) and I...was advised of the allegations...denied...After initially denying the allegations...finally admitted squirted water on this Resident (#1) and had taken a photo of (Resident's bare buttocks and had text it to (CNA #2's sibling)...used a syringe to spray...did not know why (CNA #2) did this...'just being stupid I guess.' (CNA #2 said...text picture to (sibling)...said...sprayed the water on Resident to wake (Resident) at 4am (4:00 a.m.) to hear Resident fuss and yell, getting mad at having being awakened...(CNA #2) further stated that the two (sisters-CNA's #3, #4) were present...and (CNA's #1 and #6) had observed the water squirting...(CNA #2) denied the picture still exists...(Administrator) viewed (cell phone) pictures, none of which appeared to be...bare buttocks and no facial pictures of any Residents of (facility)...CNA #2 had what appeared to be personal or family photos...(Administrator) advised (CNA #2) that these actions are unlawful...(Administrator) informed...at this point on administrative leave...(Administrator) requested statement..." Review of a written statement (no date), by CNA #2 revealed, "...I squirted water on the ceiling above the bed..." Review of the facility policy "Resident Abuse Prevention" (no date), pages 27 through 29, revealed, "Each Resident has the right to be free from abuse...Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff..."Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish...Resident Abuse Reporting, Investigation, and Protection:...It is the intent of (facility) to ensure that all Residents are free from abuse by providing a safe, secure environment. Reporting:...Employees are to immediately report to their supervisor any allegation of abuse...Incidents include: staff-to-Resident...Any employee, who is made aware of alleged/suspected abuse acts, must immediately report the situation...Protection: When an employee is alleged or suspected to have committed an abusive act, the accused employee shall be immediately suspended without pay by the supervisor pending the investigation of the allegations..." Review of the facility policy "Cellular Phone Policy" (no date), pages 68 through 69, revealed, "Policy: (Facility) prohibits the use of personal cellular phones in any (facility) owned building during working hours...Procedures: Use of Personal Cellular Phones: Employees will be required to keep personal cellular phones in their vehicles...If an employee is caught with their personal cellular phone in a (facility)...during working hours the cellular phone will be taken from them by their supervisor and will not be returned to them until the end of their shift...Violations of this policy will be subject to the highest forms of discipline, including termination.." Review of Employee Time Cards dated January 13, 2012, through January 14, 2012, and January 16, 2012, through January 17, 2012, revealed CNA's #2, #3, and #4 were not immediately suspended after the allegations of abuse were initially reported to RN #1 on January 14, 2012, at approximately 4:00 a.m.: CNA #2 worked beginning at 6:24 p.m., on January 13, 2012, ending at 6:53 a.m., on January 14, 2012; and worked beginning at 6:23 p.m., on January 16, 2012, ending at 6:54 a.m., on January 17, 2012. CNA #3 worked beginning at 6:24 p.m., on January 13, 2012, ending at 6:54 a.m., on January 14, 2012; and worked beginning at 6:28 p.m., on January 16, 2012, ending at 6:54 a.m., on January 17, 2012. CNA #4 worked beginning at 6:24 p.m., on January 13, 2012, ending at 6:54 a.m., on January 14, 2012; and worked beginning at 6:28 p.m., on January 16, 2012, ending at 6:54 a.m., on January 17, 2012. Review of a facility surveillance video on January 26, 2012, at approximately 10:30 a.m., in the DON's office, and in the presence of the Administrator and DON, confirmed CNA's #2, #3, and #4 worked January 16-17, 2012, (between 6:30 p.m.-7:00 a.m.) and worked on the hall where Resident #1's and #2's rooms were located. Continued review of the video confirmed CNA #2 and #6 entered Resident #2's room; Resident #1's room was accessible to the CNA's through a bathroom shared by the Residents (#1 and #2). Both the Administrator and DON confirmed the CNA's (#2, #3, and #4) were working on the hall of Resident #1 and #2, on January 16-17, 2012, (between 6:30 p.m.-7:00 a.m.). Interview with CNA #4 on January 25, 2012, at 1:05 p.m., in the conference room, confirmed Resident #1 was squirted, using a syringe with tap water, ice water, and toilet water from the Resident's commode, by CNA's #2, #3, and #4. Continued interview revealed other staff were present and observed the Resident being squirted by CNA's #2, #3, and #4, on different occasions, to include CNA's #1 and #6 (observed in December 2011 or January 2012); CNA's #5 and #8 (observed in January 2012); and LPN #1 (observed in January 2012). Continued interview confirmed Resident #2 was squirted with tap water "one time by each of us" (CNA's #2, #3, and #4) and (Resident #2) gave no response other than barely mumbled. CNA #4 denied knowledge or involvement of any pictures or videos. CNA #4 confirmed "squirting the (Residents) was abuse." Interview with CNA #3 on January 25, 2012, at 1:38 p.m., in the conference room, confirmed Resident #1 was squirted, using a syringe with tap water, ice water, and toilet water from the Resident's commode, by CNA's #2, #3, and #4, starting sometime between November 2011 and December 2011. "It didn't happen every night, but did happen once-to-two times a week." CNA #3 stated the squirting was initially done to see what Resident #1 would do. When "squirted with water, (Resident #1) would get aggravated and yell...I guess it was (Resident's) Dementia...would cuss and say all kinds of stuff, such as calling out for (spouse)." CNA #3 confirmed "I took a picture of Resident #1 getting into bed with Resident #2...Resident #1 had a hospital gown on and it was open in the back, exposing (Resident #1's) naked buttocks as (Resident #1) got into the bed...I thought it was cute." CNA #3 stated showed the picture to CNA #2, who requested a text copy of the picture; CNA #3 confirmed did send a text copy of the picture to CNA #2. Continued interview revealed CNA #3 observed CNA #2 video Resident #1 with a cell phone, while sitting up on the bedside, with the hospital gown down and around the waist with the Resident's breasts exposed. Continued interview confirmed Resident #2 was squirted with tap water by (CNA's #2, #3, and #4) during the month of December 2011. "(Resident #2) didn't respond to the squirting, so the squirting stopped." Continued interview revealed other staff were present and observed the Resident being squirted by CNA's #2, #3, and #4, to include CNA's #1 and #6 (observed in December 2011); CNA's #5 and #8 (observed in January 2012); and LPN #1 (observed in December 2011). CNA #3 revealed LPN #1 upon observing the CNA's squirt the Resident "laughed." CNA #3 confirmed "squirting (Residents #1 and #2) was abuse...although I didn't take the picture to be mean, it was abuse." Interview with CNA #1 on January 25, 2012, at 3:15 p.m., in the conference room, revealed CNA #1 witnessed CNA #2 obtain a saline-filled syringe from LPN #1, around the first week in January 2012. Continued interview with CNA #1 revealed CNA #2 squirted Resident #1 with the saline, then tap water, then proceeded to the Resident's bathroom and filled the syringe with toilet water from the commode and squirted Resident #1. CNA #1 was "shocked and had never seen anything like this before." CNA #1 reported the abuse on January 14, 2012, before 4:00 a.m. Interview with CNA #5 on January 25, 2012, at 3:45 p.m., in the conference room, revealed on the night shift of January 13, 2012, beginning at 6:30 p.m., and ending on January 14, 2012, at 7:00 a.m., CNA's #5, #2, #3, #4, #and #8 were sitting and charting at a table beside the upstairs nurse's station. CNA #2 stated, "Let's go get (Resident #1) riled (to annoy, anger, or irritate) up." Continued interview revealed the CNA's got up and proceeded to the Resident's room. Prior to entering Resident #1's room, CNA #2 commented something about "needing just the right syringe." CNA's #5, #3, and #8 entered Resident #1's room; CNA's #2 and #4 disappeared. The Resident was sitting on the bedside, and then lay down in the bed. A stream of water shot out from the bathroom toward Resident #1, hitting the wall above the Resident's bed. CNA #5 reported was unable to see into the bathroom, but based upon CNA #2's statement at the table just minutes prior to this, CNA #5 determined CNA's #2 and #4 were in the bathroom. CNA #5 confirmed this behavior was abusive to the Resident. Interview with CNA #7 on January 25, 2012, at 5:00 p.m., in the conference room, confirmed "sometime in December" CNA #2 showed a picture of a Resident on their side, naked buttocks showing, and feces on a pad under the Resident. Continued interview with CNA #7 revealed CNA #7 asked CNA #2 "Why would you take a picture like that," and CNA #2 replied "To show my (sibling) what we deal with every night." CNA #7 reported the picture was of a Resident. Continued interview with CNA #7 confirmed, "I knew it was abuse when I was viewing the picture and I should have reported it." Interview with RN #1 on January 25, 2012, at 9:14 p.m., by telephone, confirmed CNA #1 reported (to RN #1) on January 14, 2012, at approximately 4:00 a.m., CNA's #2, #3, and #4, were abusing Resident #1 by squirting (Resident) with water, to include used toilet water, and had taken pictures and a video with cell phones. Continued interview revealed RN #1 was "in shock" from CNA #1's allegations and went upstairs around 4:40 a.m., into Resident #1's room. RN #1 stated the head of the bed and the wall above the head was soaked and the Resident was wiping (the Resident's) face, stated, "Trying to get the water out." Continued interview revealed two CNA's (#3, #8) were in the Resident's room, and were asked by RN #1 why the Resident was wet. The CNA's shrugged their shoulders like they didn't know and replied, "She does that a lot (spills water)." Continued interview with RN #1 confirmed CNA's #2, #3, and #4 were not immediately suspended based upon the abuse allegations reported by CNA #1. Continued interview confirmed RN #1 did not notify the DON until January 15, 2012, "around" 3:00 p.m. (more than 24-hours after the allegations of abuse). Continued interview with RN #1 confirmed CNA's #2, #3, and #4 worked their full shifts (6:30 p.m.-7:00 a.m.) beginning on January 16, 2012. Interview with CNA #2 on January 26, 2012, at 11:30 a.m., in the conference room, confirmed the squirting of Resident #1 started in December 2011. CNA #2 pulled a pocket calendar from the CNA's purse, opened it, flipped through it to the month of December 2011 and pointed to the date of December 19, 2011, and confirmed, "I came in on the 19th and the squirting of (Resident #1) started around 4:30 a.m., during the round to get Residents up...on the first night of the squirting, CNA's #3, #4, #1, and #6 were present...I pulled up the tap water into a syringe and squirted the light fixture above the Resident's bed hoping the water would drip onto (Resident #1)...little drops trickled onto (Resident's) shoulder and (Resident) pulled the covers up and went back to sleep, so we left the room...on other occasions, we (CNA's #2, #3, #4) used tap water, then ice water from the bottom of the ice chest on the hall, then toilet water from the commode until (Resident #1) was awake and agitated...(Resident) would curse and yell out, "(Spouse's name) leave me the hell alone." "I nicknamed (Resident) ("spouse's name")." Continued interview revealed CNA #2 took a picture "during the first two weeks of November (2011)" of an incontinence pad soiled with feces with no Resident(s) in the picture. CNA #2 stated showed the picture of the soiled incontinence pad to RN #2 and revealed RN #2 did not counsel CNA #2 for having a cell phone on duty. CNA #2 confirmed CNA #3 took a picture on a cell phone of Resident #1's naked buttocks. CNA #2 requested CNA #3 to text the picture to CNA #2, to "show my (sibling)." CNA #2 recalled seeing and getting this picture from CNA #3 sometime in November or December 2011, "It was prior to December 16, 2011, because that's when I got my new cell phone and I lost all the pictures I had." CNA #2 confirmed to have used a cell phone to video Resident #1 during an agitated state "around" the last of December 2011; during the "rant" Resident #1 was "sitting up on the edge of the bed with a hospital gown on...(Resident's) breasts were very large and during the rant, they may have been exposed." Continued interview revealed "we all had our cell phones with us...in our pockets, on the floor, in Residents' rooms..." Continued interview revealed CNA #2 showed the video to CNA #1, and then deleted it. CNA #2 revealed LPN #1 gave CNA #2 a saline filled syringe from a medicine cart on the hall. Continued interview confirmed LPN #1 was present and observed the CNA's (#2, #3, and #4) squirting Resident #1 on one occasion. When the surveyor asked what LPN #1 did to correct the abusive action or to protect the Resident in response to squirting the Resident, CNA #2 replied, "Nothing." Continued interview with CNA #2 confirmed all three CNA's worked a full shift from 6:30 p.m. to 7:00 a.m., on January 13-14, 2012, and January 16-17, 2012. Upon reporting to work on January 16, 2012, CNA #1 confirmed, "We were not reassigned, or told we could not go on the hall where Residents #1 and #2 were, and we were not told we couldn't provide care to them...this was never mentioned." CNA #2 confirmed, "Squirting the Residents, taking pictures and making the video was abuse and we thought it was funny...we should not have done this." Interview with RN #1 on January 26, 2012, at 6:05 p.m., in the conference room, revealed the RN was "shocked" when (RN #1) saw the CNA's (#2, #3, and #4) at work on January 16, 2012. Upon informing the RN of the video and the surveyor observing the three CNA's working on the hall of Residents #1and #2, RN #1 confirmed, "The Charge Nurses could not ensure the CNA's were not on the victims' hall; this all could have been avoided if they (CNA's #2, #3, and #4) had not been allowed to work." Interview with RN #2 on January 26, 2012, at 4:30 p.m., in the conference room, confirmed CNA #2 did show RN #2 a picture of an incontinence pad soiled with feces. RN #2 stated instructed CNA #2 to delete the picture, but took no action. Continued interview confirmed the RN had observed CNA's #2, #3, and #4 texting and talking on their cell phone during their shifts. RN #2 stated "reminded" the CNA's not to be using their cell phones. RN #2 confirmed CNA's #2, #3, and #4 were non-compliant with the use of cell phones in the facility. Interview with LPN #1 on January 26, 2012, at 8:30 p.m., in the conference room, revealed LPN #1 denied witnessing any CNA's squirting any resident(s). Continued interview with LPN #1 stated, "There's a lot of "hustle and bustle" on night shift and I don't remember giving a CNA a syringe." Continued interview with LPN #1 confirmed, I did see CNA #1 with a personal cell phone...(the cell phone) had a mood app (application) on it, like a "mood ring"...you put your thumb on it and it would tell you your mood." LPN #1 stated when (LPN #1) placed a thumb on the app, it said "I was loved." Interview with CNA #6 on January 30, 2012, at 5:00 p.m., in the conference room confirmed the first time CNA #6 witnessed CNA #2, #3, and #4 squirting Resident #1 was on December 20, 2012, at approximately 3:00 a.m. - 4:00 a.m. "(Resident #1) would sit up in bed and cuss and yell "get the hell out of here...quit pissing on me." Continued interview with CNA #6 confirmed, "Yes, this was abuse...No, I didn't report it." Interview with CNA #2's sibling on January 31, 2012, at 6:00 p.m., by telephone, confirmed the sibling did not receive a text from CNA #2, but was shown a picture on the CNA's cell. The picture was of a Resident with a hospital gown on, with the naked buttocks exposed. CNA #2 confirmed to the sibling the picture was of a Resident in CNA #2's care at the facility where CNA #2 worked. "This picture was shown to me by CNA #2 sometime during the month of November 2011." Interview with the DON on January 30, 2012, at 2:15 p.m., in the conference room confirmed the allegations of abuse, as reported to RN #1 by CNA #1 on January 14, 2012, at approximately 4:00 a.m., were not reported immediately to the DON until January 15, 2012, at 4:45 p.m., over 24-hours later. Continued interview confirmed the CNA's (#2, #3, and #4) were allowed to work after the allegations of abuse and were not suspended immediately to protect the victims or other potential victims. Continued interview with the DON confirmed residents #1 and #2 were abused; the facility failed to immediately suspend the alleged perpetrators (CNA's #2, #3, and#4), report the allegations and protect the victims and other potential victims. Interview with the Administrator on January 26, 2012, at 2:05 p.m., in the conference room confirmed the DON called the Administrator and reported the abuse on January 15, 2012, at 9:03 p.m. The Administrator stated squirting the residents was "unlawful" and was abuse. Continued interview confirmed the facility failed to protect residents #1 and #2 from abuse when facility staff failed to follow and enforce the facility's abuse and cell phone policies. C/O

Based on medical record review, review of the facility timeline and investigation, review of facility policy, review of employee time cards, review of a facility surveillance video, and interview the facility failed to protect two Residents (#1 and #2) with Dementia from physical and mental abuse of five Residents reviewed. The facility failed to stop abuse immediately and report the witnessed abuse after Resident #1 was abused, allowing three alleged perpetrators, Certified Nursing Assistants (#2, #3, and #4), to continue to abuse Resident #1 and Resident #2. The facility's failure to follow facility policy to report abuse immediately and remove the alleged perpetrators and protect the residents placed all Residents with Dementia in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a Resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on January 30, 2012, at 4:00 p.m. The Immediate Jeopardy was effective January 14, 2012 and is ongoing. A partial extended survey was conducted on January 31, 2012. Substandard Quality of Care was cited under tag F-223 and F-226 at a scope and severity level of a "J". The findings included: Review of the facility policy "Resident Abuse Prevention" (no date), pages 27 through 29, revealed, "Each Resident has the right to be free from abuse...Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff..."Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish...Resident Abuse Reporting, Investigation, and Protection:...It is the intent of (facility) to ensure that all Residents are free from abuse by providing a safe, secure environment. Reporting:...Employees are to immediately report to their supervisor any allegation of abuse...Incidents include: staff-to-Resident...Any employee, who is made aware of alleged/suspected abuse acts, must immediately report the situation...Protection: When an employee is alleged or suspected to have committed an abusive act, the accused employee shall be immediately suspended without pay by the supervisor pending the investigation of the allegations..." Review of the facility policy "Cellular Phone Policy" (no date), pages 68 through 69, revealed, "Policy: (Facility) prohibits the use of personal cellular phones in any (facility) owned building during working hours...Procedures: Use of Personal Cellular Phones: Employees will be required to keep personal cellular phones in their vehicles...If an employee is caught with their personal cellular phone in a (facility)...during working hours the cellular phone will be taken from them by their supervisor and will not be returned to them until the end of their shift...Violations of this policy will be subject to the highest forms of discipline, including termination..." Interview on January 30, 2012, at 2:15 p.m., with the Director of Nursing (DON) in the conference room confirmed the allegations of abuse, as reported to Registered Nurse (RN #1) by Certified Nursing Assistant (CNA #1) on January 14, 2012, at approximately 4:00 a.m., were not reported immediately to the DON until January 15, 2012, at 4:45 p.m., over 24-hours later. Continued interview confirmed the CNA's (#2, #3, and #4) were allowed to work after the allegations of abuse and were not suspended immediately to protect the victims or other potential victims. Continued interview with the DON confirmed residents #1 and #2 were abused; the facility failed to immediately suspend the alleged perpetrators (CNA's #2, #3, and#4), report the allegations and protect the victims and other potential victims. Interview on January 26, 2012, at 2:05 p.m., in the conference room with the Administrator confirmed the DON called the Administrator and reported the abuse on January 15, 2012, at 9:03 p.m. The Administrator stated squirting the residents was "unlawful" and was abuse. Continued interview confirmed the facility failed to protect residents #1 and #2 from abuse when facility staff failed to follow and enforce the facility's abuse and cell phone policies. Refer to F223 Substandard Quality of Care C/O

Based on survey results dated January 31, 2012, the facility failed to ensure two Residents (#1 and #2) with Dementia were free from physical and mental abuse of five Residents reviewed. The facility failed to follow facility policy to report abuse immediately and remove the alleged perpetrators and protect the residents, allowing the three alleged perpetrators to continue to abuse the victims. The facility provided an acceptable Credible Allegation of Compliance on February 13, 2012. A revisit conducted on February 15, 2012, revealed the corrective actions, implemented on February 13, 2012, removed the Immediate Jeopardy. Non-compliance for F-223 continues at a "D" level scope and severity. Validation of the Credible Allegation of Compliance was accomplished through facility policy review, review of inservice records, interview with staff, administrative personnel, residents and families, and observation. The facility provided evidence of new policies and procedures which were implemented on January 23, 2012, related to the enforcement of following the policy to stop and report abuse immediately and the enforcement of the cell phone policy, which prohibited the use of personal cell phones and cameras in the facility. Inservice and training records including sign-in sheets for all staff related to the new policies were provided. The sign-in sheets for the training records were compared to a listing of all employees and confirmed 100% (percent) of all employees had been trained on the new policies. Interview with staff, including Certified Nursing Assistants (CNA's), Restorative Nursing Assistants (RNA's), Licensed Practical Nurses (LPN's), Registered Nurses (RN's), Environmental Services (Housekeeping/Laundry), Physical Therapist (PT), and Director of Nursing (DON) confirmed staff had been inserviced on the abuse and reporting policies, cell phone policies, and the likelihood of termination for not stopping and reporting abuse, or if caught with a personal cell phone in the facility. Continued interview confirmed at the beginning of each staff rotation, Charge Nurses question staff to ensure understanding of the cell phone policy, and to see if staff have personal cell phones with them. No staff has been caught with their personal cell phone. Random interviews with alert and oriented residents and with family members confirmed no observations had been made of staff with cell phones in the facility. Observation revealed the Crimes Reporting policy was posted in the main lobby, at the time clocks, at the elevators, and in the medicine rooms. Observation revealed no cell phones were observed being used in the facility. Based on review of facility abuse and cell phone policies implemented on January 23, 2012, for stopping and reporting abuse, review of inservice records, interview and observation, the Immediate Jeopardy was removed during the revisit survey dated February 15, 2012. The facility will remain out of compliance at a Scope and Severity level "D"-a pattern of deficient practice that constitutes no actual harm with potential for more that minimal harm that is not Immediate Jeopardy. The facility remains out of compliance until it provides an acceptable plan of a correction to include monitoring to ensure the deficient practice does not recur and the facility's corrective measures could be reviewed and evaluated by the Quality Assurance Committee.

Based on interview and review of a facility surveillance video, the facility failed to be administered in a manner to protect two Residents (#1 and #2) with Dementia from abuse; to immediately suspend the three alleged perpetrators, Certified Nursing Assistants (#2, #3, and #4); failed to ensure policies were followed for investigation and reporting of the abuse; and failed to ensure Residents were protected from further abuse of five Residents reviewed. The facility's failure has caused abuse of two Residents (#1 and #2) and has placed other Residents at risk for abuse. The facility's failure placed all Residents with Dementia in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a Resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on January 30, 2012, at 4:00 p.m. The Immediate Jeopardy was effective January 14, 2012 and is ongoing. A partial extended survey was conducted on January 31, 2012. Substandard Quality of Care was cited under tag F-223 and F-226 at a scope and severity level of a "J". The findings included: Interview with Registered Nurse (RN #1) on January 25, 2012, at 9:14 p.m., by telephone, confirmed Certified Nursing Assistant (CNA #1) reported (to RN #1) on January 14, 2012, at approximately 4:00 a.m., CNA's #2, #3, and #4, were abusing Resident #1 by squirting (Resident) with water, to include used toilet water, and had taken pictures and a video with cell phones. Continued interview revealed RN #1 went upstairs around 4:40 a.m., into Resident #1's room. The head of the bed and the wall above the head was soaked and the Resident was wiping (the Resident's) face, and stated, "Trying to get the water out." Continued interview revealed two CNA's (#3, #8) were in the Resident's room, and were asked by RN #1 why the Resident was wet. The CNA's shrugged their shoulders like they didn't know and replied, "She does that a lot (spills water)." Continued interview with RN #1 confirmed CNA's #2, #3, and #4 were not immediately suspended based upon the abuse allegations reported by CNA #1. Continued interview confirmed RN #1 did not notify the DON until January 15, 2012, "around" 3:00 p.m. (more than 24-hours after the allegations of abuse). Continued interview with RN #1 confirmed CNA's #2, #3, and #4 worked their full shifts (6:30 p.m.-7:00 a.m.) beginning on January 16, 2012. Review of a facility surveillance video on January 26, 2012, at approximately 10:30 a.m., in the Director of Nursing's (DON's) office, and in the presence of the Administrator and DON, confirmed CNA's #2, #3, and #4 worked January 16-17, 2012, (between 6:30 p.m.-7:00 a.m.) on the hall where Resident #1 and #2's rooms were located. Continued review of the video confirmed CNA #2 and #6 entered Resident #2's room; Resident #1's room was accessible to the CNA's through a bathroom shared by the Residents (#1 and #2). Both the Administrator and DON confirmed the CNA's (#2, #3, and #4) were working on the hall of Resident #1 and #2, on January 16-17, 2012, (between 6:30 p.m.-7:00 a.m.). Interview on January 26, 2012, at 4:30 p.m., in the conference room, with RN #2 confirmed CNA #2 did show RN #2 a picture of an incontinence pad soiled with feces. RN #2 instructed CNA #2 to delete the picture, but took no action. Continued interview confirmed the RN had observed CNA's #2, #3, and #4 texting and talking on their cell phone during their shifts. RN #2 "reminded" the CNA's not to be using their cell phones. RN #2 confirmed CNA's #2, #3, and #4 were non-compliant with the use of cell phones in the facility. Interview on January 30, 2012, at 2:15 p.m., with the DON in the conference room confirmed the allegations of abuse, as reported to RN #1 by CNA #1 on January 14, 2012, at approximately 4:00 a.m., were not reported immediately to the DON until January 15, 2012, at 4:45 p.m., (over 24-hours later). Continued interview confirmed the CNA's (#2, #3, and #4) were allowed to work after the allegations of abuse and were not suspended immediately to protect the victims or other potential victims. Interview on January 26, 2012, at 2:05 p.m., in the conference room with the Administrator confirmed the DON called the Administrator and reported the abuse on January 15, 2012, at 9:03 p.m. Continued interview confirmed the facility failed to report the abuse immediately and failed to suspend CNA's #2, #3, and #4 immediately once the abuse was reported to protect the victims or other potential victims. Refer to F223 Substandard Quality of Care Refer to F226 Substandard Quality of Care C/O

Based on survey results dated January 31, 2012, the facility failed to be administered in a manner to enforce the facility's abuse policy to protect two Residents (#1 and #2) with Dementia from abuse; to immediately suspend the three alleged perpetrators; failed to ensure policies were followed for investigation and reporting of the abuse; and failed to ensure Residents were protected from further abuse of five Residents reviewed. The facility provided an acceptable Credible Allegation of Compliance on February 13, 2012. A revisit conducted on February 15, 2012, revealed the corrective actions, implemented in February 13, 2012, removed the Immediate Jeopardy. Non-compliance for F490 continues at a "D" level scope and severity. Validation of the Credible Allegation of Compliance was accomplished through facility policy review, review of inservice records, interview with staff, administrative personnel, residents and families, and observation. The facility provided evidence of new policies and procedures which was implemented on January 23, 2012, related to the enforcement of stopping and reporting abuse immediately and the enforcement of the cell phone policy, which prohibited the use of personal cell phones and cameras in the facility. The facility provided evidence that all staff, including administrative staff, had been re-inserviced and trained on the facility's abuse policies related to stopping and reporting abuse immediately, protection of the resident, and suspending the alleged perpetrators immediately. Further review confirmed evidence that all staff, including administrative staff, had been in-serviced and trained on the facility's cell phone policies, which prohibits the use of personal cell phones and cameras in the facility. The sign-in sheets for the training records were compared to a listing of all employees and confirmed 100% (percent) of all employees had been trained on the facility's abuse and cell phone policies. Interview with staff, including Certified Nursing Assistants (CNA's), Restorative Nursing Assistants (RNA's), Licensed Practical Nurses (LPN's), Registered Nurses (RN's), Environmental Services (Housekeeping/Laundry), and Physical Therapist (PT) confirmed staff had been inserviced on the abuse and reporting policies, cell phone policies, and the likelihood of termination for not stopping and reporting abuse, or if caught with a personal cell phone in the facility. Continued interview confirmed at the beginning of each staff rotation, Charge Nurses question staff to ensure understanding of the cell phone policy, and to see if staff have personal cell phones with them. No staff has been caught with their personal cell phone. Interview with the Administrator and the Director of Nursing (DON) confirmed they had been in-serviced and trained by the facility's Chief Executive Officer (CEO) on enforcing abuse and reporting policies and cell phone policies. Random interviews with alert and oriented residents and with family members confirmed no observations had been made of staff with cell phones in the facility. Observation revealed the Crimes Reporting policy was posted in the main lobby, at the time clocks, at the elevators, and in the medicine rooms. Based on review of facility abuse and cell phone policies implemented on January 23, 2012, review of inservice records, interview and observation, the Immediate Jeopardy was removed during the revisit survey dated February 15, 2012. The facility will remain out of compliance at a Scope and Severity level "D"-a pattern of deficient practice that constitutes no actual harm with potential for more that minimal harm that is not Immediate Jeopardy. The facility remains out of compliance until it provides an acceptable plan of a correction to include monitoring to ensure the deficient practice does not recur and the facility's corrective measures could be reviewed and evaluated by the Quality Assurance Committee.