Autumn Care of Marshville

Inspectors wroteBased on observation, record review, and interviews with Resident #101, the resident's Power of Attorney (POA), and staff, the facility failed to follow professional standards of practice for medication administration for 1 of 1 resident reviewed (Resident #101) when Nurse #3 crushed and administered Atorvastatin 40 mg (milligrams), a medication used to lower cholesterol and reduce the risk of cardiovascular events such as heart attack and stroke.

Inspectors wroteBased on record review, Physician and staff interviews, the facility failed to have effective systems in place for shift change narcotic reconciliation and failed to keep discontinued narcotic medications under two locks for return to the pharmacy. This failure resulted in 30 missing oxycodone/acetaminophen 10/325 milligrams (mg) and 50 missing oxycodone 5 mg for a total of 80 missing tablets. This occurred for 2 of 2 residents reviewed for misappropriation of medications (Resident #98 and Resident #103).

Inspectors wroteBased on observation, record review, and interviews with Resident #101's Power of Attorney (POA), Facility Physician, Pharmacist, Nurse Practitioner #1 (NP), and staff, the facility failed to ensure Resident #101 was free from a significant medication error when Nurse #3 crushed and administered Brivaracetam (anticonvulsant medication used to control partial -onset seizures) 100 milligram (mg) extended-release, Eslicarbazepine 800 mg (anticonvulsant used to treat seizure disorders), Lamotrigine 200 mg (anticonvulsant medication used to control various types of seizures), and Xcopri 150 mg (anticonvulsant used to treat partial-onset seizures), despite physician orders indicating the medications were to be administered whole and not crushed. This deficient practice occurred 1 of 1 resident reviewed for significant medication errors (Resident #101).

Inspectors wroteBased on record review and interviews with the Power of Attorney (POA), the Nurse Practitioner, three dental offices, the dental Chief Compliance Officer, Chief Medical Officer, and facility staff, the facility failed to ensure necessary assistance was provided to obtain routine and emergency dental services for 1 of 1 resident reviewed (Resident #95).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #2). Resident #2 was prescribed a daily low-dose aspirin for stroke prevention. Nursing Assistant (NA) #1 rolled Resident #2 away from her during incontinence care, and Resident #2 fell out of bed sustaining a laceration to her forehead, which necessitated 8 sutures to close.

Inspectors wroteBased on record review and staff and physician interviews, the facility failed to complete and document ongoing comprehensive assessments for a resident after an unwitnessed fall and to have effective systems in place for communicating changes in condition. Resident #1 was severely cognitively impaired and had an unwitnessed fall from bed on 1/5/2025. Resident #1 was assessed by a nurse immediately after the fall, with no pain or injury noted at that time. This was the only documented nursing assessment. During the 7:00 AM to 3:00 PM shift on 11/6/2025, a nurse aide observed Resident #1 wince when she was turned on her left side during care, and this was not reported to a nurse. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to disinfect a dedicated resident glucometer according to the manufacturer's germicidal disinfectant instructions for 1 of 1 observations of glucometer disinfection (Nurse #1).

Inspectors wroteBased on record review and staff interviews the facility failed to post accurate totals of licensed nurses for 4 of 4 days (11/1/2024, 11/2/2024, 11/3/2024, and 11/4/2024) reviewed for posted nurse staffing.

Inspectors wroteBased on record review, and staff and Medical Director (MD) interviews, the facility failed to notify the physician for a resident who had a significant change in condition. On [DATE] Resident #1 was observed with audible congestion, difficulty swallowing, and was trying to cough up phlegm. The MD or Nurse Practitioner (NP) were not notified. On [DATE] Resident #1 had his mouth open with clear phlegm noted in his mouth and he was coughing. Resident #1's vital signs included a blood pressure (BP) of 90/86 (normal 120/80), pulse of 48 (normal range 60-100), oxygen at 89% (normal range between 95% and 100%) on room air, and respirations of 12 (normal range 12-18). He had audible congestion, and his skin was extremely hot to touch. The MD or Nurse Practitioner (NP) were not notified. At 5:00 AM Resident #1 was found not breathing and was pronounced deceased at 6:15 AM. [...]

Inspectors wroteBased on record review, and physician, Nurse Practitioner (NP), and staff interviews, the facility failed to protect a resident's right to be free from neglect when staff failed to provide necessary care and services for 1 of 3 residents reviewed for neglect. Resident #1 had a significant change in condition on [DATE] and the nurse did not recognize the seriousness, notify the physician or provide thorough and ongoing assessments. In addition, Resident #1 was found not breathing and without a pulse on [DATE] and Cardiopulmonary Resuscitation (CPR) was not immediately administered. Resident #1 was pronounced deceased by emergency medical services (EMS) on [DATE]. This was for 1 of 3 residents reviewed for neglect (Resident #1).

Inspectors wroteBased on observation, record review, staff, and Nurse Practitioner (NP) interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered immediately and failed to operationalize an effective system so staff could respond to an emergency situation as needed. On 9/19/24 Nurse #1 was notified that Resident #1 was unresponsive, not breathing and had no pulse. Nurse #1 verified Resident #1 was not breathing. Nurse #1 did not verify Resident #1's code status and resumed her nursing duties on another hall. Nurse #1 was later informed that Resident #1 was a full code, Nurse #1 then started CPR without initiating a code blue protocol. Nurse #1 stopped CPR when she became tired. Resident #1 was pronounced deceased by emergency medical services (EMS) on 9/19/24. This was for 1 of 3 residents reviewed for CPR (Resident #1).

Inspectors wroteBased on record review and staff, Nurse Practitioner (NP) and Medical Director (MD) interviews the facility failed to provide complete, thorough, and ongoing assessments, and failed to intervene when Nurse #1 failed to recognize the seriousness of a resident's (Resident #1) change in condition. Resident #1, who was a full code, was experiencing a change in condition on [DATE] with symptoms of difficulty swallowing, audible congestion (able to hear without the use of stethoscope), and trying to cough up phlegm. Nurse #1 did not obtain vital signs or put interventions into place to relieve the congestion. On [DATE] Resident #1 had his mouth open, clear phlegm was noted in his mouth, audible congestion continued, and he was coughing. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code the behavior section and failed to code the medication section on the Minimum Data Set (MDS) assessment for 2 of 5 residents reviewed for MDS accuracy. (Resident #34, and #39).

Inspectors wroteBased on record review, observation and staff interviews the facility failed to provide feeding assistance (Resident #54) for 1 of 5 residents who were dependent on staff for their activities of daily living needs (ADL) needs.

Inspectors wroteBased on observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification dated 11/4/21 for one deficiency in the area of Activities of Daily Living (ADL) for dependent residents. The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective Quality Assurance program.