**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and resident, staff, Physician, Nurse Practitioner (NP), Physician Assistant (PA) and neurology office Scheduler interviews the facility failed to ensure a neurology appointment was scheduled for a resident (Resident #14). The Physician ordered a neurology referral for Resident #14 first on 8/23/24 for evaluation of her tremors. A second neurology consult was ordered by the NP on 11/5/24 again for evaluation of her tremors. Resident #14 had tremors to her upper and lower extremities, including her hands and feet. Resident #14 reported her tremors had worsened, were unmanageable, made her feel awful, and like she could not do anything. Resident #14 reported the tremors made her not want to leave her room because she did not want people to see her in that state. She stated she felt isolated every day and felt down, depressed, and hopeless all the time because nothing was getting better. This occurred for 1 of 1 resident reviewed for medically related social services (Resident #14). Findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses that included depression, anxiety, mood disorder (depression/ mania), essential tremor (involuntary shaking typically in arms/ hands), drug induced secondary Parkinson's disease (a movement disorder that is caused by medications and causes Parkinson's disease symptoms). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. She was not documented as having behaviors or rejection of care. A history and physical dated 8/23/24 by the Medical Director (MD) read in part: Patient today is complaining of significant ongoing worsened tremors. She reports she has been evaluated by multiple neurologists in the past however no significant improvement has been made. She reports primidone (a medication used to treat tremors) has been helpful. She was previously on a higher dose. She has trialed Sinemet (a medication used to treat symptoms of Parkinson's such as tremors) with no relief of the symptoms. Reports the tremors are giving her some difficulty completing activity of daily living (ADL) including self-feeding. She does report some ongoing increased mood symptoms. Will refer back to neurology services for further recommendations. Resident #14's active physician orders revealed an order dated 8/23/24 entered by the Medical Director (MD) that read: Please refer back to neurology for tremor. Review of Resident #14's electronic medical record revealed there were no records of a neurology appointment being scheduled. A telephone interview was conducted with the MD on 12/5/24 at 1:21 PM. The MD said Resident #14's neurology appointment should have been scheduled by the facility when she had ordered the referral in August. The MD stated she was not aware a neurology appointment had not been scheduled for Resident #14 after she had given the order for the referral in August. She explained she was not surprised Resident #14 had not been seen yet by neurology because a new patient referral with neurology could take a long time. The MD indicated it was hard to say 100% if there were any negative effects from Resident #14 being seen later by neurology. She explained she did not know if neurology would make a huge difference but that it was good to get a specialist's opinion because they knew more about it. The MD said she was not sure if neurology would be able to help improve Resident #14's tremors but having a neurologist input was an important part of the puzzle. A progress note dated 8/27/24 by NP #1 read in part: She [Resident #14] reports her tremors are interfering with her desire to be around others. Patient is anxious and becoming upset as she discusses her tremors. A psychiatric progress note dated 8/29/24 by PA #1 read in part: She is taking Primidone which interacts with Latuda (antipsychotic medication) and causing extrapyramidal symptoms (EPS) (movement disorders that can occur as a side effect of certain medications), involving significant generalized tremor and muscle twitching. Changes included stopping Latuda, starting Risperidone (antipsychotic medication) 1 milligram (mg) every morning and 2 mg every night for schizoaffective disorder (mental health condition), and starting Benztropine (a medication used to treat movement problems) 0.5 mg every 8 hours as needed (PRN) for tremors/ EPS. A psychiatric progress note dated 9/5/24 by PA #1 indicated Resident #14 had seen an improvement in EPS since Latuda was switched to Risperidone and PRN Benztropine was added. A progress note dated 9/13/24 by NP #1 said Resident #14 reported shaking in her knees and she had tremors to her bilateral upper extremities and jaw that were tardive dyskinesia (TD) (a movement disorder typically caused by taking certain medications, such as antipsychotic medications) or essential tremors. The note stated, it is wondered if the shaking in her knee is part of these known tremors. A progress note dated 9/24/24 by NP #1 read in part: Today her chief complaint is her anxiety and her tremors. She states her tremors are worse today than yesterday. Yesterday her Benztropine was discontinued as her tremors had escalated with the three times daily dosing. She is asking to be placed back on her regimen where it was dosed twice daily, and her tremors were better managed. Today her anxiety seems to be driven by her tremors. A psychiatric progress note dated 9/26/24 by PA #1 indicated Resident #14 reported her tremors were worse on Benztropine. The note stated she had tremors present primarily to her bilateral upper extremities. The Benztropine was stopped and Artane (a medication used to treat tremors) 1 mg twice daily was added for EPS. A psychiatric progress note dated 10/11/24 by PA #1 indicated Resident #14 reported some benefit from the Artane but the effects waned midday. Artane orders were changed to 1 mg three times daily for EPS. A psychiatric progress note dated 10/31/24 by PA #1 indicated the Artane three times daily dosing was reported to have caused an increase in Resident #14's tremors. The note said Resident #14 had been refusing the medication because she felt it was causing her tremors to increase. She had also refused her antipsychotic medication. The note revealed Resident #14 denied any return of psychosis symptoms and reported she had only had a single episode of psychosis in her lifetime in the context of grief related to a significant death and questions the validity of the diagnosis. The note revealed Resident #14 no longer wanted to take an antipsychotic medication at all but agreed with allowing the medication to be tapered. Artane was stopped and Risperidone was decreased to 1mg nightly. A progress note dated 11/5/24 by NP #1 read in part: She is very discouraged today and frustrated by her tremors. She reports she has been evaluated by neurology in the past regarding her tremors and that she was told there was nothing that could done about them. When asking if she would like to have a second opinion regarding her tremors she responded to the affirmative. Review of Resident #14's active physician orders revealed an order dated 11/5/24 entered by NP #1 read: neurology consult for tremor, make appointment with a [local] neurologist. A psychiatric progress note dated 11/14/24 by PA #1 read in part: Resident #14 EPS seems worse since stopping both the Artane and Risperidone. She is in some distress over this, feeling frustrated and pessimistic about the future. She is experiencing marked tremulousness in her upper extremities and has been confining herself to her bed most of the time. We discussed treatment options for tardive dyskinesia, and she is receptive to trial of Ingrezza (a medication used to treat tardive dyskinesia). Ingrezza 40 mg daily was added for TD. A psychiatric progress note dated 11/21/24 by PA #1 read in part: Resident #14 presented in a markedly irritable manner today, raising her voice in anger, as she has continued to have symptoms of TD. She has been markedly shaking in her upper extremities, essentially unchanged from when she was last seen and has been spending time in her room much of the time as a result. We discussed the etiology of this, but she was not receptive, and it is not clear to what degree she understood due to her angry state. Changes were made to her medications. Carbidopa-levodopa (a medication used to treat Parkinson's symptoms) 25-100 mg twice daily was added for EPS and Trazodone (a medication used to treat anxiety) 25 mg twice daily was added for anxiety. An interview was conducted with NP #1 on 12/5/24 at 12:40 PM. She explained the psychiatric PA followed Resident #14 for monitoring and management of her tremors. NP #1 stated she had recently seen Resident #14 and had asked her if she had ever been seen by a neurologist. She recalled Resident #14 told her she had been seen by a neurologist in Waynesville and had been told there was not anything else they could do for her tremors. NP #1 explained Resident #14 had preferred to go see a neurologist in Asheville for a second opinion. NP #1 stated she had made the referral for neurology for Resident #14 because her tremors had not gotten better. She explained several different medications had been trialed for Resident #14 to help with her tremors. NP #1 further explained, some of the medications that were trialed may have made the tremors worse, so those had been stopped and now Resident #14's tremors were back to baseline but not getting better. NP #1 said Resident #14's tremors bothered her and affected her quality of life. She said Resident #14 had told her she does like to go to activities much because of her tremors. NP #1 explained Resident #14's tremors did not impact her ability to perform task such as eating but that it was more of a self-image issue and caused her not to want to socialize. She said Resident #14 tremors affects her depression symptoms because of how they affect her life, she explained Resident #14 was followed by psychiatry services to address her psychiatric diagnoses and symptoms. NP #1 stated Resident #1's tremors were not basic essential tremors. She explained there was a psychiatric component to her tremors that needed to be managed by psychiatry and neurology. NP #1 was not aware a neurology referral had previously been made for Resident #14 in August, she said I just knew she needed to go. NP #1 explained she did not think there was physical harm from Resident #14 being seen later by neurology but that maybe there was emotional harm related to anxiety/ depression being worse. NP #1 stated emotionally it would have been better if Resident #14 would have been seen sooner by neurology for her to have some answers. A telephone interview was conducted with PA #1 on 12/5/24 at 12:14 PM. He said he followed Resident #14 for psychiatric services. He explained he provided monitoring and management for her tremors. He explained that had been the focus since Resident #14 had been admitted to the facility. PA #1 further explained Resident #14 had been admitted with a diagnosis of schizoaffective disorder. He said her Latuda and Primidone interacted and caused an increase in EPS. PA #1 stated he had tried different medications for Resident #14 to manage her tremors but that they did not work. He said Resident #14's tremors had waxed and waned since she had been admitted to the facility. PA #1 said the tremors made Resident #14 anxious and when she was anxious it caused them to worsen. He recalled the last time he had seen Resident #14 she had yelled at him and that was new. He said he had stopped her antipsychotic entirely and she had not had new psychosis. PA #1 said Resident #14's was irritable due to not sleeping well and shaking all the time. He said her tremors sometimes interfered with her sleep and that affected her concentration and mood too. PA #1 explained there were times Resident #14's tremors seemed to get a litter better and then they would get worse again. He said he was unaware of how long or to what degree she was shaking prior to coming to the facility. He said he was aware of the neurology referral and had asked a nurse a couple of weeks ago if there had been a neurology referral put in for Resident #14. He explained at first, he had thought he could manage Resident #14's tremors but when they did not get better, he had thought she would need a neurology referral. He stated he could not remember which nurse he had asked about the neurology referral. PA #1 stated he had not been aware a neurology referral had been made previously for Resident #14 in August. PA #1 said he was not sure if Resident #14's tremors could ever go away but was hopeful they could get to a manageable level where she would be able to hold a cup of coffee. PA #1 explained he thought Resident #14 had drug induced parkinsonian symptoms and a neurologist would be appropriate and beneficial for her. He said Resident #14 had feelings of hopelessness, was irritable, and anxious because the tremors were not getting any better. An interview and observation were conducted with Resident #14 on 12/5/24 at 2:30 PM. Resident #14 was observed in her room, laying on her bed, with the lights off. She was observed to have significant shaking of both her hands and arms at rest and with movement. Shaking was also noted in her legs and feet. Resident #14 said she had tremors before she had been admitted to the facility but not like this. She explained she now had shaking in her legs and feet. She said her tremors had gotten worse since being at the facility and over the last 3-4 weeks they had become unmanageable. Resident #14 explained different medications had been tried since she had been at the facility to help with her tremors. She said every time her medications were changed it makes me worse and that makes me feel anxious. Resident #14 stated her tremors made her feel awful and like she could not do anything. She explained they made her not want to leave her room and stated, I just don't want people to see me in that state. Resident #14 said she felt isolated every day and felt down, depressed, and hopeless all the time because nothing was getting better. Resident #14 was not aware a neurology referral had been ordered for her in August and that no one had come to talk to her about it. She explained she had been seen by a neurologist but that it had been several years since she had been seen. Resident #14 said she would have been okay going to an appointment with same neurologist office if she could have been seen sooner. An interview was conducted with the facility Scheduler on 12/5/24 at 11:00 AM. The facility Scheduler stated if there was an order written for a referral she would fax the appointment referral to the medical office. She explained she would give the office a week or two to call her to schedule the appointment and then if she did not hear from the office, she would call the office to schedule the appointment. The facility Scheduler stated she saved the referrals and 1 to 2 times a month she would sit down and go through the referrals. She explained she would discard the referral if the appointment had been made and would call the office for the ones that had not been scheduled. She stated she did not remember if she had called the neurology office or followed up on the neurology appointment ordered in August for Resident #14 specifically. The facility Scheduler explained she had been working on the floor, helping stock supplies, and had not been at her desk as much to give appointments attention. The facility Scheduler stated she had gotten behind on appointments and had not kept up with them as good as she should have. She explained that the Director of Nursing (DON) and Administrator had talked to her about the appointment process and how it was not working in October. The facility Scheduler stated she needed a new process to keep track of appointments, and she was now using a spread sheet to keep up with appointments. She explained she had faxed the referral for Resident #14 to the neurology office on 8/30/24 and had not heard back from the office to schedule the appointment. She said she did not receive any missed calls or messages from the neurology office regarding scheduling the appointment. The facility Scheduler stated she did not remember if she had called the neurology office to follow up on scheduling the appointment for Resident #14. She said she had faxed the neurology referral ordered on 11/5/24 for Resident #14 to the neurologist's office on 11/6/24. She explained she called them on 11/27/24 to follow up on the referral and the office stated they had not received the referral. She stated she had faxed the referral to the office again on 11/27/24. The facility Scheduler said she had called the office this morning and they had scheduled Resident #14 for an appointment on 2/20/25. A telephone interview was conducted with the neurology office Scheduler at the neurology office on 12/5/24 at 11:00 AM. She stated the neurology referral had been faxed to the office on 8/30/24 by the facility and the office had made multiple attempts to contact the facility to schedule a neurology appointment for Resident #14. She explained the office had called the facility's Scheduler at the number provided on the faxed referral. She provided the number the neurology office had called to attempt to schedule the appointment. The phone number had matched the number present on the faxed referral sheet by the facility that had been confirmed as the correct number by the facility's Scheduler. The neurology office stated they had called and left messages on 9/4/24, 9/11/24, 9/12/24, and 9/16/24 for the facility's Scheduler to call back to schedule an appointment for Resident #14. She stated she knew the dates the office had called and left messages on the phone number provided by the facility, because there were notes about the phone calls, dates, and messages in their system. She explained after the fourth attempt on 9/16/24 the office had closed the referral because they had been unable to reach anyone to schedule the appointment. The neurology office scheduler stated Resident #14 had been an established patient with the office but had not been seen since February of 2022. She explained if the office had called the facility, it was because they had an appointment and could get Resident #14 in to be seen. She said the neurology office booked appointments for about 3-4 months out and that most likely Resident #14 would have been seen in November or December if the facility had followed up on the referral sent on 8/30/24. An interview was conducted with the DON on 12/5/24 at 3:25 PM. The DON stated Resident #14 should have had a neurology appointment scheduled after the first order had been given in August. She stated the Appointment Scheduler should have talked with Resident #14 to see if she already had a neurologist she had seen previously or what Neurologist she wanted to go to see. The DON said she was not sure what happened and why the appointment was not made. The DON stated the Appointment Scheduler should have followed up with the neurology office if she had not heard back from them in a week. She explained an issue had been noticed in October with appointments not being followed up on and tracked. The DON stated before October there was not a process in place for following up on appointments, tracking appointments/ referrals, or accountability. She stated there had not been a schedule book and appointments had been logged in the Appointment Scheduler's phone. The DON explained the process the facility now had for referrals/ appointments. She said when an order was entered by a provider for a referral the order was pending and had to be confirmed by a nurse. She further, explained when a referral order was confirmed, the order was printed, and given to facility Scheduler either by placing it on her desk or putting it in her box. The DON said the referral should be faxed to the office when the facility Scheduler received the referral order. She stated if the facility Scheduler had not heard back from the office within a week about a referral, she should call the office to follow up. She stated the facility Scheduler made a list of appointments for the week and she reviewed them on Fridays and checked them against referral orders on the computer. The DON was not aware the neurology appointment ordered on 11/5/24 had not been scheduled until today. She was not sure why there had been a delay in scheduling the 11/5/24 neurology appointment or why the referral had not been followed up on for 3 weeks. The DON explained Resident #14 needed to go to neurology to have their input on the tremors and hopefully give her some improvement in her quality of life. She said even if going to neurology eased Resident #14's mind then it was worth it. An interview was conducted with the Administrator on 12/5/24 at 5:01 PM. The Administrator stated she was not sure about what happened with the neurology appointment that had been ordered in August or how it had been missed being scheduled. She did not say who had been responsible for appointments when the facility Scheduler had been out. She stated she would expect that if the facility Scheduler had not heard back from the office in a week that she would call the office to see why. The Administrator said there had not been a process for appointments, follow up, or accountability before October 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, the facility failed to provide 2 staff members when using a sit-to-stand mechanical lift for 1 of 2 residents (Resident #21) as per the care plan which resulted in a fall with fractures of the distal tibia (shin bone) and fibula (calf bone) with displacement. The findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, charcot's joint of the right ankle and foot (a complication which affects the bones, joints, and soft tissues of the foot and ankle causing the bones to become weak and break, or the joints to dislocate), type 2 diabetes, and lumbago with sciatica (pain that radiates along the sciatic nerve which runs down one or both legs from the lower back). Review of the quarterly Minimum Data Set, dated [DATE] for Resident #21 revealed he was cognitively intact and required extensive assist of 1 person for transfers. Resident #21 had a care plan dated 12/16/20 in place for falls and activities of daily living where it stated he required a mechanical lift assist with 2 staff members for transfers. Interview on 12/13/21 at 10:14 AM with Resident #21 revealed he had a fall in March 2021 from a nurse aide not using the stand-up lift with 2 people. Resident #21 stated a few days later he thought his sciatica was acting up, he went to the hospital, and found out his left leg was broken. Review of the incident report dated 3/12/21 for Resident #21 revealed the nurse stated she was called into the shower room by the nurse aide and saw Resident #21 had slid down from the sit-to-stand lift. The nurse reported Resident #21 stated he slid down in the sit-to-stand lift during a transfer with his left foot and leg under him. Review of the nurse note dated 3/12/21 for Resident #21 revealed he had experienced leg weakness and slid down in the sit-to-stand lift. Resident #21 was assessed by the nurse, had no apparent injury, and did not complain of any pain or discomfort. Review of the nurse note dated 3/16/21 for Resident #21 revealed the nurse was called to therapy to look at Resident #21's left ankle. Resident #21 told the nurse he had rolled his ankle in the shower a few days prior on Friday when transferring to the wheelchair, but he had no pain, discomfort, or swelling with the ankle over the weekend. Resident #21 told the nurse he had rolled his left ankle again in therapy and the ankle was now painful, bruised, and swollen. Review of the physician orders dated 3/16/21 for Resident #21 revealed and order for x-ray to left ankle/foot due to swelling, bruising, and pain, and an order to transfer to the emergency room for evaluation and treatment of left tibia/fibula fractures. Review of the radiology results report dated 3/16/21 for Resident #21 revealed acute fractures of the distal tibia and fibula with displacement. The hospital Discharge summary dated [DATE] revealed Resident #21 presented to the emergency department on 3/16/21 after experiencing a fall, resulting in the fracture of his left ankle. In addition, the x-rays noted a displaced left distal tibial fracture with a comminuted (breakage of bone into more than two fragments) distal fibula fracture. Resident #21 had an intramedullary nail fixation ( permanent nail/rod is placed in the center of the bone) on 3/18/21 and due to the amount of bruising and swelling the fibula could not be repaired at that time. It was noted this would be addressed at the outpatient follow-up in approximately two weeks. Review of a progress note dated 3/22/21 revealed Resident #21 was seen by the physician assistant to review overall status upon readmission following surgical fixation of the left distal tibia/fibula fracture. It was documented Resident #21 complained of ankle pain in the facility last week after a fall in the shower room. Interview on 12/15/21 at 5:53 PM with Nurse Aide #1 revealed she had assisted Resident #21 out of the shower and back into his wheelchair on 03/12/21. Nurse Aide #1 stated she had Resident #21 in the sit-to-stand mechanical lift and his right knee gave out on him and she lowered him to the floor. Nurse Aide #1 revealed she asked Resident #21 if he was hurting anywhere and he said no. Nurse Aide #1 stated she went and got the nurse who also asked Resident #21 if he was hurting which he again denied any pain, so they assisted Resident #21 up to his wheelchair. Nurse Aide #1 revealed she was not aware she was to use 2 staff with the sit-to-stand mechanical lift. Interview on 12/15/21 at 4:35 PM with Nurse #4 revealed the nurse aide had came and told me Resident #21 had slid down from the sit-to-stand lift. Nurse #4 stated Resident #21 had said his left leg hurt a little bit but there was no swelling or discoloration. Nurse #4 revealed Resident #21 was his usual self, laughing with her and the nurse aide and they had assisted Resident #21 back to the wheelchair. Nurse #4 stated Resident #21 did not complain of any pain to her after that. Nurse #4 also stated she did not think there was another nursing staff member assisting the nurse aide with the sit-to-stand lift with Resident #21. Interview on 12/16/21 at 1:21 PM with the Director of Nursing (DON) revealed staff should follow the facility's mechanical lift policy and she expected staff would use a 2 person assist with a mechanical lift. Interview on 12/16/21 at 1:45 PM with the Administrator revealed staff should follow the policy for mechanical lift usage and he expected staff would use 2 people with the mechanical lift at all times.