CHARLOTTE, NC- SATURN NURSING AND REHABILITATION CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on observations, record review, resident, physician, and staff interview the facility failed to protect a severely cognitively impaired resident from the right to be free from physical abuse (Resident #5). Resident #5 experienced physical abuse twice on [DATE] when before bingo Resident #4 placed her arm around the Resident #5’s neck, and pulled her forward, and then on the same day, placed Resident #5 in a chokehold with her arm while she was seated in her wheelchair. Resident #5 was held in the chokehold position which caused the resident to gasp and her face to become red. In addition, the facility failed to protect a severely cognitively impaired resident from the right to be free from sexual abuse (Resident #3). Resident #3 experienced sexual abuse on [DATE] when Resident #2 touched and rubbed her pubic area. Based on the reasonable person concept, being placed in a chokehold and non-consensual sexual contact would cause a
reasonable person to experience psychosocial harm, trauma and fear from physical or sexual abuse. Abuse occurred for 2 of 4 sampled residents reviewed for protection from abuse (Resident #5 and Resident #3).

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on a resident interview, staff interviews and record review, the facility failed to report an incidence of physical abuse to facility administration to protect a resident from further physical abuse. Resident #5 experienced physical abuse twice on 12/27/23. Both incidents occurred on 12/27/23 before 2:30 PM. Resident #4 first physically assaulted Resident #5 in the dining room. This occurrence of physical abuse was not reported to the facility administration. As a result, Resident #4 physically assaulted Resident #5 again in the hallway. The deficient practice occurred for 1 of 4 sampled residents reviewed for abuse (Resident #5).

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Based on record review and staff interviews the facility failed to develop a comprehensive person-centered individualized care plan for a resident with behaviors for 1 of 3 sampled residents (Resident #4).

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

Based on staff interviews and record review, the facility failed to have an accurate facility assessment that recorded the current Medical Director and changes to administrative personnel. This failure occurred for a facility census of 99 residents.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Based on observations, record review, and staff interviews, the facility’s Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of 08/13/21, the complaint investigation survey of 09/29/22 and the current complaint investigation survey of 4/29/24. This failure occurred for three repeat deficiencies originally cited in the areas of freedom from abuse and neglect, develop and implement abuse and neglect policies, and comprehensive resident centered care plans that was subsequently recited on the current complaint investigation survey of 4/29/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility’s inability to sustain an effective QAA Program.