**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident, staff, Responsible Party/Power of Attorney, North Carolina Nursing Assistant Registry investigator, former Director of Nursing and law enforcement interviews, the facility failed to protect a resident's (Resident #1) right to be free from misappropriation of property when Nursing Assistant (NA) #1 used Resident #1's bank account information, without Resident #1's permission, to create a Cash App account (Cash App is an app on your phone that works like a digital wallet; it is connected to your bank account and can be used to send or receive money instantly between users as well as be used to pay bills or for services) in Resident #1's name and then used that Cash App account to transfer money to her adult son, fiance, and mother on several occasions. NA #1 was alleged to have spent approximately $8022.84 (estimated) from November 2024 through March 2025. Resident #1 said it made her mad and that it hurt here (indicating her heart by patting the center of her chest) knowing NA #1 had stolen her money. This deficient practice occurred for 1 of 1 resident reviewed for abuse, neglect and misappropriation of resident property (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic diastolic (congestive) heart failure, chronic kidney disease stage 2, generalized anxiety disorder, and major depressive disorder. Resident #1's Care Plan included a need of impaired mobility related to hemiplegia following cerebrovascular disease (a stroke) affecting right side, initiated on 7/19/24. The quarterly Minimum Data Set (MDS), dated [DATE], coded Resident #1 as cognitively intact. A review of the facility's Summary of admitted Charges from Staff Member, listed the transactions on Resident #1's bank statements from 11/12/24 through 3/20/25 that totaled $8,022.84. The Initial Allegation Report, dated 3/27/25 and completed by the Administrator, was reviewed. It indicated the facility became aware on 3/27/25 at 8:30 AM that Resident #1 allegedly gifted NA #1 money. NA #1 had been suspended pending an investigation for misappropriation of resident property. Local law enforcement was notified on 3/27/25 at 9:30 AM. The Department of Social Services was notified on 3/27/25. A fax receipt indicated the Division of Health Service Regulation was notified on 3/27/25 at 9:41 AM. The Investigation Report, dated 4/2/25 and completed by the Administrator, was reviewed. The report indicated the facility did not substantiate the allegation of misappropriation of resident property. It stated the incident did not result in injury/harm or mental anguish to Resident #1. It indicated the new estimated amount was $8102.84 based on their follow-up interview. Per this report, law enforcement for this incident did not result in any charges against NA #1. Further review of the facility's 5-day summary revealed the facility had become aware of some concerns regarding Resident #1's bank account when a family member of hers brought in Resident #1's bank statement into the Business Office Manager (BOM) on 3/26/25. The family member told the BOM that someone is getting Resident #1. After some research, there had been a correlation between some transactions on the bank statement to NA #1 as she shared the same last name with the names listed on the Cash App transactions listed on the statement. The Administrator brought in NA #1 on the morning of 3/27/25 and NA #1 admitted to accepting financial gifts from Resident #1 and the transactions were completed via Cash App accounts in the names of her mother and son; NA #1 initially denied any transaction tied to her fiance. The summary listed the total of the transactions in her son and mother's names as $5825.15. A follow-up interview with NA #1 revealed an admission by NA #1 that she had, with Resident #1's permission, covered bills from Rent-A-Center and Spectrum. A follow-up interview with Resident #1 on 4/1/25 indicated Resident #1 changed her story in that she never gifted any staff gratuities or that she ever agreed to use her card to process any bill payments for staff. The summary included the facility updating the local police department's officer of these new details. The summary concluded as follows: Based on the investigation which includes the identified staff member's admitting of accepting monies from [name of Resident #1] and processing payments for herself with her alleged permission from [name of Resident #1] and [name of Resident #1] giving conflicting statements over multiple interviews, the allegation of misappropriation is unsubstantiated. The employee has been terminated effective 4-2-2025 for facility policy violation related to accepting gratuities. The Burgaw Police Department Incident/Investigation Report, incident number 2025-00671, completed by a Patrol Officer for the police department on 3/27/25 was reviewed. The report indicated the officer went to the facility and had been informed by the facility Administrator that Resident #1 had deposited money into several Cash Apps accounts that were tied to NA #1 (her own, her mother's, and her child's) over the past 4 months, totaling an amount of $5825.15 that was stolen from Resident #1. The officer stated the Administrator explained to him that the situation had been brought to their attention by Resident #1's family member (an aunt) who received mail at her address from Resident #1's bank and had noticed numerous Cash App transactions. The officer wrote that the Administrator went on to explain that when he questioned Resident #1 and NA #1, he had been informed those transactions were gifts and that the Administrator had also informed him that the facility's investigation was still ongoing. An attempt to contact the Burgaw Police Department's patrol officer via telephone was unsuccessful on 8/20/25 at 3:27 PM as the officer was not on duty on this date. A telephone interview with a Detective Sergeant of the Supportive Services Division at the Burgaw Police Department on 8/21/25 at 8:30 AM revealed the case was closed however, a warrant had been taken out against NA #1 by a Corporal within the department. The Detective Sergeant suggested this surveyor speak with the Corporal of the Police Department. A telephone interview with the Corporal of the Burgaw Police Department was conducted on 8/21/25 at 8:51 AM. The Corporal explained he was not on duty and did not have the paperwork of the case in front of him and therefore unable to give specifics in regard to dates and amounts but was able to offer what he knew of the details of the case. He explained the facility's Administrator had reported the incident to the patrol officer who, in turn, reported the case to him. The Corporal stated he went to the facility and talked with the Director of Nursing (DON) who provided him with information regarding the incident. This information included how NA #1 had Resident #1's banking account information and attached that to several Cash App accounts within her family and then used those accounts to pay for things such as bills and furniture. The Corporal stated the DON informed him that Resident #1 was not able to make decisions based on her BIMS (brief interview for mental status, an assessment tool used to determine a resident's mental cognition) score and that the DON had explained to him what a BIMS score was as well as having informed him of their policy about employees not being able to take tips or gratuities from residents. The Corporal went on to say that he had spoken to NA #1 who told him that Resident #1 had given her permission to use Resident #1's money to pay her bills. The Corporal gave examples of what some of those Cash App accounts had been used to pay for, such as pizza, birthday cake, a birthday planner, getting nails done at a spa, among other places. He said NA #1 had told him that other employees had done it in the past as well. He said NA #1 said times were tight and that she admitted to him that she had taken advantage of Resident #1, that she knew it was wrong even though Resident #1 had given her permission to do so. The Corporal stated he asked NA #1 about the facility's policy about not being allowed to take tips or gratuities from residents and that NA #1 denied knowledge of that policy and explained to him that she did not have a good orientation when she had been hired. The Corporal stated how this all came to light was that Resident #1's aunt had been made aware of these Cash App transactions after Social Security had made an overpayment of $10,000 in Resident #1 payments and had sent a letter explaining the overpayment would have to be paid back and that the aunt had gone to the facility to discuss that matter as well as the matter of all those Cash App transactions on Resident #1's bank account statements. The Corporal stated NA #1 was charged with exploitation of an elder and has been served with that process and now the case is in the hands of the court. He explained she had her first court appearance last month and may be on her second or third court appearance by now. He stated once NA #1 had been served, he submitted all of his evidence to the [NAME] County District Attorney (DA) and to NA #1's defense attorney. He recalled NA #1 telling him that she would pay everything back to Resident #1. The Corporal stated what NA #1 did was considered a felony and that she could serve time in jail but admitted she could also get probation, which is sometimes usual in cases like this. The Corporal added that he had spoken with Resident #1 who stated that she never gave NA #1 permission to use her bank account information; he stated he also talked with Resident #1's aunt, who agreed that Resident #1 would never have given NA #1 her permission to access that money in her bank account and that Resident #1 would not have been able to create a Cash App account. An interview was conducted with Resident #1 on 8/20/25 at 3:10 PM. Resident #1 recalled NA #1 referring to her as her mother, like in a friendly way at first, but stated she was not related to NA #1 at all. She said once, they started talking about Chinese food and she told NA #1 that if she would go and pick her up some Chinese food that she would buy some for her as well. Resident #1 said she gave NA #1 a $20 bill and confirmed she never gave NA #1 her debit card. Resident #1 stated that when NA #1 returned from the restaurant and put the change in the top drawer of the dresser beside her bed, she said NA #1 noticed her bank statements that were in that drawer and took them. Resident #1 stated that NA #1 then took information from those statements and set up a Cash App account in her name. Resident #1 confirmed she had never heard of Cash App before all of this happened and that the Business Office Manager (BOM) had to explain to her how it worked. Resident #1 said after she found out about all the Cash App transactions that showed up on her bank statements, she told NA #1 to return her bank statements to her or else she would call the police. Resident #1 said the police came to the facility and told her that NA #1 used her bank information to create a Cash App account in her name and then used the account for different things and that NA #1 had stolen a lot of money from her. She said after that, she saw her bank statements and all of her money was gone it made her mad and it made her hurt here, patting the center of her chest with her hand. She denied ever giving NA #1 permission to take any money from her bank account and remained adamant she had never given NA #1 her bank debit card. Resident #1 stated she wanted her money back in her bank account. A telephone interview was conducted with NA #1 on 8/19/25 at 2:04 PM. NA #1 was initially reluctant to agree to an interview and questioned whether this information would be shared with the news people. NA #1 expressed anger towards the facility and how they had handled their investigation. She complained that the Administrator slandered her name and then she decided she would like to tell her side of the story. NA #1 explained she had developed a close relationship with Resident #1 and how the resident would refer to her as a daughter and because Resident #1 had lost a child, she thought being called her daughter was sweet. She said a lot of people at the facility knew of their relationship and no one considered that a problem until a family member of Resident #1's got involved because of something to do with Social Security money. NA #1 further explained that Resident #1 had been threatened by her family and by the facility's BOM that if she did not pay back Social Security, she would be kicked out of the facility. NA #1 continued, saying that prior to the Social Security stuff, Resident #1 would do things for her and gave an example of once Resident #1 offered to do Christmas for her boys. NA #1 stated Resident #1 would cling onto her and ask her to do personal things and, in turn, Resident #1 would offer to help her financially. NA #1 said Resident #1 was in her right mind and everything was fine until Resident #1's family got involved. NA #1 acknowledged the facility was trying to say it was a lot of money but that it had only been $2000 or $3000 here and there. NA #1 denied ever having been arrested over this situation. She explained her lawyer is working with the DA and that she will have to pay restitution which would be a certain amount of money and was unable to explain further and said that she did not really understand what that meant. NA #1 continued to tell her side of the story and said around 3 months after everything had happened, she received a call from the [NAME] County Sheriff's office and then they came to her house and then she had to speak to the DA. She said the DA told her she was not being charged with anything dealing with fraud, but then said she had been charged with misappropriation of elderly something and could not remember fully what it was called, and thought it might have to do with the fact they said I took advantage of her because they had looked at her record and saw Resident #1 was incompetent and then said, but Resident #1 holds her own bank cards and stuff and makes her own financial decisions. NA #1 stated she would not have to go to jail and talked again about the restitution and said that until that is paid, the case would be pending but that when restitution is paid off, the case would be dismissed. An interview was conducted with the BOM on 8/19/25 at 2:52 PM. The BOM explained that around the 25th or 26th of March 2025, Resident #1's Responsible Party (RP)/next of kin came to see her and had brought in one of Resident #1's bank statements. The RP informed her that someone is getting her and showed her the bank statement which listed several Cash App transactions. The BOM stated she then went with the RP and another staff member to Resident #1's room to talk with her. Once in the room, she stated they asked Resident #1 what all those Cash App transactions were and who were the people she had been Cash Apping. The BOM stated Resident #1 did not know what they were talking about. She explained that at that point, she left the resident's room to go and get her phone, and the RP had opened the drawer to her dresser and looked at other bank statements she found there. She stated that they saw these Cash App transactions had been going on for a long time and with Resident #1's permission, she called the bank, explained what they had seen, and got Resident #1's bank card canceled and requested copies of all of her bank statements. The BOM stated Resident #1 had given permission to the bank for them to send her those statements. The BOM explained how she did not recognize the names associated with the Cash App transactions on the bank statement but that the last name of those listed shared the same last name of one of their employees, NA #1. She further explained that she pulled that NA #1's personnel file and also looked at her Facebook account and noticed that the emergency contacts listed in the personnel file matched the names on the Cash App transactions on the bank statements and noticed that the Facebook account listed the name of another name associated with the Cash App transactions - the employee's son. The BOM stated the transactions ranged in amounts from $20 to $1200. The BOM stated the only reason the RP had opened up and looked at Resident #1's bank statement was because of a letter from Social Security that explained Resident #1 had been overpaid by $10,000 over the course of a 2-3 year period and a letter from Social Security had been sent which stated they would be garnishing her wages in order to recoup the overpayments. The BOM stated at that point, she informed the Administrator. She explained she and the Administrator interviewed Resident #1 and that Resident #1 informed them that she liked to give gratuities to staff for a good job but that she admitted she had never given permission for any staff to use her bank card. The BOM continued and said that Resident #1 stated she knew NA #1 had taken a picture of her debit card because she heard the snap of a phone camera. The BOM said she and the Administrator met with NA #1 the following morning and said that at the beginning of the meeting, NA #1 denied using Resident #1's bank card but then later admitted to agreeing on amounts of money for Resident #1 to tip her and said that NA #1 stated she did not have Resident #1's bank card info stored on her phone. The BOM stated during their investigation, they pulled NA #1's timecards and noticed that 75% of the time observed on the Cash App transactions that NA #1 was not working and that they had asked her about that and NA #1 denied knowledge about that. The BOM stated there were multiple Cash App transactions for Spectrum [an internet/cable provider], Airbnb [a hospitality platform], Rent-A-Center, Progressive Insurance, [NAME] Financial to name a few. The BOM said the police were later called. A second interview with the BOM was conducted via telephone on 8/28/25 at 8:29 AM. The BOM stated if Resident #1 would not be able to meet her Patient Monthly Liability (PML) because of the Social Security Administration's garnishment of Resident #1's monthly benefits check secondary to having received overpayment in her monthly benefits check, then there would be a risk for her being discharged from the facility. The BOM provided a copy of the letter from Social Security Administration's letter to Resident #1 dated 3/14/25. A review of the letter Resident #1 received from the Social Security Administration (SSA), dated 3/14/25, revealed an overpayment of $9099 from September 2023 through February 2025. The letter indicated that if the SSA did not receive a refund of the amount of the overpayment from Resident #1 within 30 days, they would withhold 10 percent of her total monthly benefit or $10 (whichever is more) starting with the payment she would receive on or about 7/3/25. An interview with the Administrator was conducted on 8/19/25 at 3:46 PM. The Administrator explained that he had been informed by the BOM about a situation involving Resident #1, NA #1 and multiple Cash App transactions showing up on Resident #1's bank statements and he stated it had been brought to the BOM's attention by Resident #1's family member. He further explained that the BOM had mentioned the possible relationship of the names associated with the Cash App transactions being tied to one of their employees, NA #1. He stated he then reached out to NA #1 and asked her to come in to meet with him. Present for the interview was himself, the former Director of Nursing (DON), the BOM and NA #1. He stated he questioned NA #1 about the Cash App transactions and that NA #1 explained that Resident #1 had insisted she take and receive money from her. The Administrator stated those transactions were in concerning amounts but that they were not even close to the total amount they would later discover. He stated NA #1 accepted some responsibility that some of the charges related to her were at the resident's insistence and she was suspended at that time pending their investigation. He stated he made notifications to the State and to the police and to Adult Protective Services. He stated he did follow-up interviews with Resident #1 and noted her story changed to having never given any money to anyone and told him that if anyone said that they were lying. The Administrator stated that because they could not get a consistent story from Resident #1 and they could not prove that staff took money from her and therefore he could not substantiate the allegation. The Administrator presented a summary of his investigation, all the notebooks of his investigation, and asked for this to be considered at past noncompliance. A second interview with the Administrator was conducted via telephone on 8/28/25 at 9:31 AM. The Administrator stated while there had never been a discussion with anyone about the facility repaying the money stolen from Resident #1's bank account by NA #1 prior to the start of this investigation, he had spoken from someone at the corporate level on this date, and assured this surveyor that the facility would restore the full amount stolen by NA #1 to Resident #1's account. He also clarified that Resident #1 would not be at risk of being discharged from the facility due to inability to meet her PML. A telephone interview was conducted with the former Director of Nursing (DON) on 8/22/25 at 10:26 AM. The former DON stated she had been in her office when Resident #1's family member came to the facility and talked with the BOM. She explained the BOM then came to her and informed her that the family member had brought bank statements which showed a bunch of Cash App transactions that the family member did not understand that. She said the BOM had looked at the names on those transactions, she tied them to one of their staff, NA #1. She stated she recalled the names on the Cash App transactions were the names of NA #1's mother, her adult son, and her fiance and they knew those names were associated with NA #1 because of the emergency contacts listed in her personnel file and from having looked at NA #1's Facebook account and saw they were associated there as well. The former DON stated she had been present for a couple of the interviews the Administrator did with NA #1. During the first interview, NA #1 initially denied the allegations. Then, on the second interview, the former DON said NA #1 admitted to the Cash App transactions but told them that Resident #1 had given her gifts and that she thought if a resident was alert that it was okay to take the gifts. The former DON said that NA #1 knew better than that and that it was never okay to take money from a resident. She stated that NA #1 tried saying that her mother had cancer and had lost her house. The former DON said that NA #1 told them that Resident #1 already had a Cash App account and told them that Resident #1's phone was not working and had given NA #1 her debit card to get some food. The former DON said they believed NA #1 had taken Resident #1's debit card and created a Cash App account in Resident #1's name on NA #1's phone and then used that Cash App account to transfer money to all those different places. The former DON said that they also believed that in addition to Resident #1's bank card, NA #1 had to have a lot of Resident #1's personal information in order to create that Cash App account and then she stole thousands and thousands of dollars from Resident #1's bank account. The former DON stated that it was sad because Social Security would be wanting Resident #1 to pay back all that money that had been overpaid and because of what NA #1 had stolen from Resident #1 that Resident #1 did not have that kind of money to pay Social Security back. A telephone interview was conducted with Resident #1's family member and Power of Attorney (POA) on 8/21/25 at 8:30 AM. The POA explained that after she became Resident #1's POA, she had opened up a bank statement and saw all kinds of transactions like a nail salon in [NAME], an Airbnb, a cell phone place, Spectrum bill and stuff like that. The POA said at that time, it totaled around $7000 worth of charges. The POA stated she had also opened up a letter from Social Security talking about back payment and stated she was confused about both and went to the facility to talk with Resident #1 about it but first stopped by to speak with the BOM. The POA stated she had asked the BOM if Resident #1 had to pay for TV at the facility because she had seen that Spectrum transaction on that bank statement. She was confused because there had also been a transaction about a cell phone bill but that it was a different provider than the one Resident #1 used for her cell phone. She said she and the BOM went to talk with Resident #1 together and asked to see other bank statements she had which were just kept in the top drawer of her dresser beside her bed. She said that Resident #1 said something about a girl taking her bank statements and then the resident was going back and forth and stated Resident #1's memory isn't good and she's in poor health. The POA said she and the BOM knew something was not right and then the BOM called Resident #1's bank and got her debit card cancelled and got them to send her another card. The POA said the BOM explained to Resident #1 that she could not keep all that stuff just out in her room and took it all and locked it up. The POA explained those bank statements showed a lot of transactions, and she knew that Resident #1 had not made them because she had been at the facility a long time. She explained the BOM told her the facility would investigate and also call the police. The POA said the DA also got involved and that she calls the DA every month trying to find out what is going on with the case. She explained Social Security wants their money back and that they are taking money every month out of her check to get that money back. When asked how much money had been taken from Resident #1's bank account, the POA said she thought it was around $22,000. A telephone interview with an investigator from the North Carolina Nursing Assistant Registry was conducted on 8/25/25 at 10:40 AM. The investigator stated during her investigation of the allegation of NA #1 stealing money from Resident #1, she conducted many interviews including ones with the BOM, Resident #1, NA #1, and the Administrator. The investigator stated that during her interview with Resident #1, she found her to be very alert and oriented, and that all Resident #1 wanted was her money back so that she could pay back Social Security for the overpayment of benefits. The investigator stated that she informed the Administrator they needed to help Resident #1 with this and said this prompted the Administrator to contact the police and conduct an investigation of the matter. The investigator stated she obtained copies of Resident #1's bank statements which showed Cash App transactions to NA #1's mother, son and fiance. During her interviews with NA #1, the investigator stated NA #1 informed her that all the transactions were small ones and denied some of the larger ones. The investigator said she definitively proved Cash App transactions made by NA #1 in the amount of $9162.15 and closed her case on 6/10/25. A telephone interview was conducted with the Administrator and Director of Nursing (DON) on 8/22/25 at 11:14 AM. The Administrator stated he could not say why NA #1 did what she did to Resident #1 as he did not get into the whys of it, that he was more concerned that they took the right actions after they had been made aware. He stated NA #1's employment with the facility was terminated on 4/2/25. Both the Administrator and the DON stated it was their expectation that staff not accept gratuities from residents and that they expect all staff to follow their policies and procedures. The Administrator submitted the following Corrective Action Plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Deficient Practice: NA #1 misappropriated Resident #1 funds and there was no negativePsychosocial or mental outcomes to Resident #1. The deficient practice occurred because NA #1 did Not follow page #14 of the employee handbook specific to Gratuities and Loans. NA #1 acknowledged receipt of the employee handbook on 10-15-2024. NA #1 was suspended 3-27-25 pending investigation. Local law enforcement was notified 3-27-25 at 9:30am, Adult Protective Services (APS) at 11:00am on 3-27-25, facility providers were notified at 10:23am on 3-27-25, Division of Health Service Regulation (DHSR) was notified by submission of the Initial Allegation Report on 3-27-25 at 9:41am by the Nursing Home Administrator (NHA), and family member of Resident #1 was notified on 3-27-25. Resident #1 was interviewed by the Nursing Home Administrator and Business Office Manager (BOM) on 3-27-25. Resident #1 stated that she liked to tip staff. With permission, Resident #1's purse was searched and loose blank checks and financial cards were found by the BOM. With permission, those items were taken and given to Resident #1's aunt by the BOM. Resident #1 was given a new locked box by the BOM on 3-27-25. Resident #1 has a Patient Trust Account and a deposit was made based on cash found with permission. A mood assessment was completed on 3-27-25 by the Social Worker (SW) for Resident #1 she was assessed to be at her baseline. Mood assessments were completed 3 times a week for two weeks beginning 4-1-25 through 4-12-25 for Resident #1 by the Social Worker and Resident #1 remained at baseline. On 5-14-2025, the administrator followed up with local law enforcement to seek out updated information regarding criminal and restitution actions.To make the resident whole, a restitution judgement was made against NA #1 by the [NAME] District Court for the State of North Carolina on 8-13-2025 for Resident #1 in the amount of $14,481.05. This restitution judgment will be managed by the [NAME] District Court for the State of North Carolina. The family for Resident #1 was made aware of local law enforcement notifications made by the Business Office Manager and the Administrator as it relates to pursuing criminal actions and restitution through local law enforcement against NA#1 for Resident #1 beginning on 3-27-2025. Resident #1's ability to stay at the facility, as it relates to Resident #1s Patient Monthly Liability, has not and will not be affected by the event caused by NA #1 per the Administrator.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.100% of interviewable residents were interviewed, offered a lock box, and educated by the Social Work department beginning on 3-27-25 and completed on 3-28-25 related to misappropriation and no other residents were affected. Interviews, offering a lock box and education related to gifts, gratuities and misappropriation of funds were completed by the BOM with responsible parties of 100% non-interviewable residents on 3-28-25 and no residents were affected. 100% of employee file audits were completed on 3-27-25 by the Human Resources (HR) Director related to abuse education, healthcare registry review, and background check verification. Newly admitted residents are offered a lock box by the admission Director or designee when completing the new admission paperwork.3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.All facility-employed staff education related to abuse and misappropriation began on 3-27-25 and was completed on 3-27-25 by Human Resources and designees. The education covered the facility's Abuse Prohibition Policy that covers physical abuse, verbal abuse, sexual abuse, exploitation, mental abuse, neglect, with an emphasis on misappropriation of resident property, to include examples of allegations of misappropriation of resident property and exploitation . The education was completed in person and via telephone by the HR Director and designees. No facility staff worked until they were educated, and this was va[TRUNCATE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviews and staff interviews, the facility failed to have advance directives in the resident's records for 1 of 7 sampled residents. (Resident #52). Findings included: Resident #52 was admitted to the facility on [DATE]. A review of Resident #52's admission's Notice of Acknowledgments dated 01/04/2023 revealed no note that the resident wanted to formulate an advance directive or refused. Significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #52's cognition was severely impaired. Review of the computerized clinical record for Resident #52 revealed no advanced directive noted in the resident's medical record. During the interview with Social Worker (SW) on 05/02/23 at 10:42 AM, she acknowledged there was no indication in the medical record if Resident #52's representative wanted to formulate an advance directive or refused to formulate one. During the interview with Director of Nursing (DON) on 05/03/2023 at 01:04 PM, she stated that the Admission's Coordinator or SW was responsible for reviewing the advance directive forms with the residents or responsible party during the admission to the facility. The DON further indicated she did not find the advance directive in Resident #52's medical record and there was no documentation found that stated the resident or responsible party refused. She added that the expectation was that the advanced directive should have been completed and scanned in Resident #52's computerized clinical record or a note indicating the refusal to formulate an advance directive. During the interview with the Administrator on 05/04/2023 at 10:30 AM, He stated the advanced directives should have been completed and scanned in Resident #52's clinical record or a note indicating refusal. The Administrator further stated he would ensure the residents' advanced directives were placed in the medical records if a resident had formulated one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of level II Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident (Resident # 78) identified as PASRR Level II. Findings included: Resident #78 was admitted to the facility on [DATE] and most recently readmitted on [DATE] after hospitalization with multiple diagnoses that included anxiety disorder, bipolar disorder, and major depressive disorder. The significant change MDS assessment dated [DATE] was left blank to question A1500 which asked if Resident #78 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. Record review indicated Resident #78 had a Preadmission Screening and Resident Review (PASRR) Level I Screen completed dated 9/14/21 for a change in condition review. Record review indicated Resident #78 had a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification dated 9/16/21. An interview was conducted with the Social Worker (SW) on 1/27/22 at 10:40 AM. The SW explained Mr. [NAME] had a completed Level II PASRR in file. The Social Worker was not aware it was not coded in the MDS data files. The Social Worker stated she usually sends an email when PASRR comes in and informs staff of the changes. She provided a copy of the updated Level II PASRR Determination Notification dated 9/16/21. An interview was conducted with the MDS Nurse on 1/27/22 at 11:35 AM. The MDS Nurse was not aware of the Level II PASRR for Resident #78 was not updated. The MDS Nurse stated she was aware of the PASRR Level II, and the care plan was updated, but it did not get updated in the MDS data. She stated she would immediately do a change in the MDS data file. An interview was conducted on 1/27/22 at 12:00 PM with the Director of Nursing and the Facility Consultant regarding PASRR II documentation. The Director of Nursing explained the Social Worker sends in the PASRR changes and notifies staff via email after receiving the updates. Resident #78 was updated in the care plan but was not updated on his MDS documentation. The Director of Nursing stated Resident #78 was missed; but should have been coded with a significant change update in the MDS data. During a telephone interview with the Administrator on 1/28/21 at 1:00 PM. He explained he had been informed about the Level II PASRR coding and it was being corrected. He stated it should have been coded with a significant change when the Level II PASRR Determination Notification was returned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to refer a resident for screening for a level II Preadmission Screening and Resident Review (PASARR) after a new mental health diagnosis for 1 of 4 residents (Resident #80) reviewed for level II PASARR. Findings included: Resident #80 was admitted [DATE] with diagnosis including dementia with behavioral disturbance 10/27/2021 and major depressive disorder 10/27/2021. The Minimum Data Set (MDS) dated [DATE] had Resident #80 coded as severely cognitively impaired and needed extensive assistance for activities of daily living (ADL). The comprehensive care plan dated 12/31/2021 had focus' of risk for pain and/or has chronic pain related to (r/t) emotional distress hallucinations, depression, delusions, and decreased mobility, arthritis, is at risk for adverse reactions and side effects r/t receiving multiple psychotropic medications. Resident takes an antidepressant for depression and a antipsychotic (Seroquel) for dementia with behaviors. The diagnosis list revealed Resident #80 was diagnosed with delusional disorders 11/12/2021, hallucinations 11/12/2021, and anxiety disorder on 12/20/2021. The NC PASARR I screen dated 11/01/2021 had major depressive disorder as one of the mental health diagnoses. The January Medication Administration Record (MAR) revealed an order for Seroquel Tablet 25 MG (Quetiapine Fumarate) Give 2 tablet by mouth at bedtime related to delusional disorders, hallucinations, unspecified, 11/15/2021 Sertraline HCl Tablet 50 MG Give 1 tablet by mouth one time a day related to major depressive disorder, recurrent, unspecified 11/11/2021. An interview with the Social Worker (SW) was conducted on 01/27/2022 at 10:35 AM. The SW stated Resident #80 was diagnosed with hallucinations, and a delusional disorder on 11/12/2021. On 12/20/2021 a new diagnosis of anxiety 12/20/2021. There was supposed to be a new PASARR level II screening completed but the resident was there a short time and it was overlooked. An interview with the Administrator was conducted on 01/27/2022 at 10:07 AM. The Administrator stated the facility had been working on PASARR's and expects all new mental health diagnosis to be followed up with a PASARR level II screening.