Autumn Care of Myrtle Grove

Inspectors wroteBased on record review and staff interviews, the facility failed to protect a cognitively impaired resident (Resident #1) with agitated behaviors from being physically restrained by an employee during care when Nurse #1 was witnessed by two other employees (Nurse Aide #1 and Nurse Aide #2) to hold Resident #1's arms down to restrict her hand and arm movements. Resident #1 screamed while being restrained by Nurse #1 and sustained bruising and pain in her bilateral hands and wrists that was relieved with as needed medications for pain following this incident. Resident #1 also had scratches to the right forearm and wrist. This occurred for 1 of 1 resident reviewed for physical restraints.

Inspectors wroteBased on record review and staff interviews, the facility failed to protect a resident's right to be free from neglect when Resident #1, a resident with severely impaired cognition and known behavioral symptoms, requested as needed pain medication from Nurse #1 and the nurse disregarded the resident's pain and withheld the medication in response to the resident spitting at her when she (the nurse) entered the resident's room. This occurred for 1 of 3 residents reviewed for abuse and neglect.

Inspectors wroteBased on record review and staff interviews, the facility failed to follow its abuse policies and procedures in the area of immediately reporting an allegation of staff to resident abuse to the Administrator and in the area of protection. This occurred for 1 of 1 resident who was investigated for a staff to resident allegation of abuse (Resident #1).

Inspectors wroteBased on observations, record review, staff and resident interviews, the facility failed to 1.) develop a person-centered comprehensive care plan as indicated by the Minimum Data Set (MDS) care area assessment to include a plan of care for a resident (Resident #9) admitted with a feeding tube. 2.) implement the use of bilateral fall mats as care planned to prevent injury in the event of a fall from bed (Resident #5) for 2 of 21 residents reviewed for care plan development and implementation. Findings Included: 1.) Resident #9 was admitted to the facility on [DATE] with diagnoses including gastrostomy (feeding) tube. The Minimum Data Set (MDS) admission assessment and care areas assessment dated [DATE] revealed Resident #9 was cognitively impaired and received tube feedings. The care area assessment indicated to initiate a care plan for Resident #9’s feeding tube. [...]

Inspectors wroteBased on record review, and staff interviews, the facility failed to maintain an environment that was free from accident hazards when a mechanical lift that was not in use was left in the hallway (600 hall) by a staff member (Nurse Aide #3) which resulted in a cognitively impaired resident with poor safety awareness and a history of falls with injury to trip over the lift while ambulating in the hallway causing a fall with minor injury of blood on her left nostril. This occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #11).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to discard four expired insulin pens according to the manufacturer's guidelines and record an opened date on an insulin pen on 1 of 4 medication carts (700 hall medication cart) that were reviewed for medication storage. Findings Included. Review of the manufacturer's guidelines for Insulin Lispro (Humalog) pens and Insulin Glargine (Lantus) pens instructed to discard 28 days after opening. An observation of the 700-hall medication cart on 8/20/25 at 11:00 AM revealed the following:Insulin Lispro (Humalog) pen with an opened date of 6/12/25 and expiration date of 7/10/25. Insulin Lispro (Humalog) pen with an opened date of 7/7/25 and expiration date of 8/5/25. Insulin Lispro (Humalog) pen with an opened date of 6/18/25 and expiration date of 7/16/25. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow the infection control policy and procedures when 1.) Medication Aide #1 entered a resident's room (Resident #73) who was on Contact Precautions due to a wound infection without donning personal protective equipment (PPE) to include gloves and a gown. 2.) Nurse Aide #1 did not don PPE for Enhanced Barrier Precautions (EPB) to include a gown when providing high-contact resident care activities for Resident #26 who had a surgical wound dressing and a lower leg dressing. This occurred for 2 of 4 staff members reviewed for infection control practices. Findings Included. 1. [...]

Inspectors wroteBased on record review and interviews with staff, the Medical Director, and the Nurse Practitioner (NP), the facility failed to immediately notify the physician on 1/25/25 of a resident's (Resident #1) dislodged jejunostomy tube (j-tube [a tube surgically inserted into the small intestine to deliver nutrition and medications]). Nurse #1 did not communicate with the physician and she inserted an indwelling urinary catheter tube to replace the j-tube without a physician's order. The replacement tube became dislodged from the j-tube site on 1/25/25 and Nurse #1 sent the resident to the hospital for reinsertion. Resident #1 went to the Operating Room (OR) on the evening of 1/27/25 and the j-tube was surgically placed. [...]

Inspectors wroteBased on record review, Nurse Practitioner (NP), Medical Director, staff, and Responsible Party (RP) interviews, the facility failed to ensure a resident (Resident #1) was provided with the necessary treatment to replace his dislodged jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine). On 1/25/25, Nurse #1 did not identify the need for hospital treatment to replace the dislodged jejunostomy tube (j-tube) and she inserted an indwelling urinary catheter tube to replace the j-tube without a physician's order. The replacement tube became dislodged from the j-tube site on 1/25/25, and Nurse #1 sent the resident to the hospital for reinsertion. Resident #1 went to the Operating Room (OR) on the evening of 1/27/25 and the j-tube was successfully placed. [...]

Inspectors wroteBased on record review and interviews with the Responsible Party, Nurse Practitioner, Medical Director and staff, the facility failed to have a system in place to train agency nurses and verify their competency to provide care for a resident with a jejunostomy tube (j-tube [a feeding tube placed in the small intestine]). On 1/25/25 when Resident #1's j-tube became dislodged, Nurse #1 did not identify the need for hospital treatment to replace the dislodged j-tube and she replaced it by inserting a urinary catheter tube into the j-tube site. Nurse #1 stated she assumed Resident #1's j-tube was a gastrostomy tube (tube placed in the stomach for nutritional support). [...]

Inspectors wroteBased on record review and staff and resident interviews, the facility failed act upon concerns that were reported by the resident council and communicate the efforts to address concerns that were reported during Resident Council Meetings for 6 of 6 months (November 2024, December 2024, January 2025, February 2025, March 2025 and April 2025) reviewed.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to residents. Nurse #2 and Nurse #3 provided tracheostomy (an opening surgically created in the neck to insert a tube into the trachea (windpipe) allowing for air to enter the lungs directly) care which included tracheal suctioning (a procedure to remove excess secretions from the airway). Nurse #2 also administered a tube feeding through a gastrostomy tube (a feeding tube placed directly into the stomach). The nurses donned gloves and a mask but no gown during the procedures. This occurred for 2 of 2 staff members (Nurse #2, and Nurse #3) who were observed for infection control practices.

Inspectors wroteBased on record review and staff interview, the facility failed to communicate all required information to the hospital for 1 of 1 resident (Resident #1) reviewed for hospital transfers.

Inspectors wroteBased on record review, staff and the Medical Director's interviews the facility failed to hold a fast-acting insulin (insulin that begins working within 15 minutes after administration) as ordered by the physician for a blood sugar level less than 150. Resident #4 was administered 2 units of sliding scale insulin with a blood sugar of 103. This occurred for 1 of 1 resident (Resident #4) reviewed for unnecessary medications.

Inspectors wroteBased on record review, staff, the Nurse Practitioner and Physician interviews, the facility failed to obtain an ordered urinalysis and culture and sensitivity (a urine test obtained to identify the presence of bacteria. A urine culture identifies the presence and type of bacteria causing an infection. Sensitivity tests determine which antibiotics are effective against the bacteria) for a resident experiencing symptoms of burning, urgency and decreased urinary output for 1 of 1 resident (Resident #3) reviewed for laboratory services.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain complete and accurate medical records for 2 of 11 residents whose medical records were reviewed (Resident #1 and Resident #4).

Inspectors wroteBased on record review and staff, Nurse Practitioner and Physician interviews, the facility failed to comprehensively assess a resident and failed to identify or recognize the significance of external rotation and shortening of the leg, severe pain, and inability to bear weight after a fall. The resident had external rotation (an outward rotation of the thigh and knee away from the body), was unable to bear weight and experienced pain from 3/4/25 (the day after a fall) through 3/10/25 at which time he was sent to the emergency room and identified with a comminuted right intertrochanteric femur fracture (most common type of hip fracture which the long bone of the thigh breaks into multiple pieces caused by a fall and is characterized by severe pain in the hip, inability to bear weight on the affected leg, and shortening and external rotation of the leg). [...]

Inspectors wroteBased on record review and staff, resident, family, Nurse Practitioner and Physician interviews, the facility failed to provide thorough and ongoing pain assessments that included identifying the source of the pain and to evaluate a resident's pain regimen when the prescribed medication was not effectively managing the resident's pain. The resident was discharged from the hospital on 3/3/25 after being admitted for pain control following a total knee replacement. The initial pain assessment on admission to the facility indicated a pain rating of 5 (on a 0 to 10 scale with 10 being the worst pain imaginable). The resident experienced a fall on 3/3/25 in the evening. The following day (3/4/25), Resident #2 experienced increased pain with a pain level ranging from 6 to 10 through 3/10/25. [...]

Inspectors wroteBased on observations, record review, and interviews with staff, residents, Nurse Practitioner, and family member the facility failed to protect a vulnerable male resident's (Resident #1) right to be free from sexual abuse by a cognitively impaired male resident (Resident #2). On 10/17/24 Resident #2 was observed by Resident #1's family member to have his hand inside Resident #1's brief as Resident #1 laid in bed. Resident #1 was incapable of giving consent for sexual contact and was unable to protect himself. Following the incident, Resident #1's antidepressant was increased due to an increase in agitation and restlessness. A reasonable person expects to be protected from abuse in their home and would have experienced psychosocial harm with feelings such as intimidation, severe anxiety, agitation, humiliation, withdrawal, and fear. [...]

Inspectors wroteBased on observations, record review, Nurse Practitioner (NP), staff, and resident interviews, the facility failed to provide supervision to Resident #7, a severely cognitively impaired resident, who asked the Weekend Receptionist to sit on the porch. Resident #7 exited from the building without nursing staff's knowledge when the Weekend Receptionist unlocked the front door and let the resident out of the facility unsupervised at approximately 12:00 PM on 9/21/2024. The resident was outside unsupervised, until Nurse #5 who was inside the building observed Resident #7 self-propelling on the road in the facility's parking lot near the curb on the right side of the building around 1:15 to 1:20 PM. The distance was approximately 332 feet from the porch of the facility. Nurse #5 instructed Nurse Aide (NA) #3 to bring Resident #7 back into the facility. [...]

Inspectors wroteBased on observation, record review, and staff, Nurse Practitioner and Physician interviews the facility failed to follow a physician order to hold a tube feeding (nutrition administered through a tube directly into the stomach) following an episode of vomiting for 1 of 1 resident (Resident #98) reviewed for tube feeding. The tube feeding that was ordered to be held was administered to Resident #98 on 1/24/24 through 1/25/24. The Nurse Practitioner observed the resident lying flat in bed, with the tube feeding running, vomit on his body, and respiratory distress symptoms that included elevated respirations, shortness of breath and decreased oxygen level. [...]

Inspectors wroteBased on observations and staff interviews the facility failed to remove the black greenish substance from the commode base caulking in resident rooms (204, 207, 302, 310, 703, 704, 705, 706, 708, 710, 712), and failed to replace broken or missing bathroom door threshold strips in resident rooms (312, 310, 710), These failures occurred on 3 of 5 hallways (200, 300, and 700 halls) observed for a safe, clean, homelike environment.

Inspectors wroteBased on observations, record review, staff, Pharmacy Manager, Consultant Pharmacist, Nurse Practitioner, and the Medical Director's interviews the facility failed to protect resident's right to be free from misappropriation of a narcotic pain medication (Hydrocodone-Acetaminophen oral tablet 5-325 milligrams) which resulted in a total of 60 missing tablets. This occurred for 2 of 2 residents (Resident #20, and Resident #61) who were reviewed for misappropriation of medications.

Inspectors wroteBased on record review and staff, registered dietician (RD) and Nurse Practitioner interviews, the facility failed to 1). obtain and record accurate weights as ordered for 4 of 4 residents reviewed for weights (Resident #83, Resident #63, Resident #91, and Resident #29) and 2). failed to verify the accuracy of 2 residents with a significant change in weight (Resident # 83 and Resident #63).

Inspectors wroteBased on observations, record review, staff, Pharmacy Manager and the Consultant Pharmacist interviews the facility failed to maintain a system of records of receipt and disposition for a controlled drug (Hydrocodone- Acetaminophen 5-325 milligrams) to enable reconciliation, and to maintain drug records in order to account for controlled drugs. This occurred for 2 of 2 residents (Resident #20 and Resident #61) reviewed for medication administration.

Inspectors wroteBased on record review, staff, Nurse Practitioner, and the Medical Director's interviews the facility failed to obtain a monthly complete blood cell count (CBC - a blood test that measures the number of red blood cells, white blood cells, and platelets in the blood) as ordered by the physician for a resident who received immunosuppressive drug therapy. This occurred for 1 of 1 resident (Resident #8) reviewed for laboratory services.

Inspectors wroteBased on record review, resident, and staff interviews the facility failed to maintain a resident's dignity when Medication Aide #1 flicked a severely cognitively impaired resident's forehead with her finger during resident care. A reasonable person expects to be treated in a respectful and dignified by their caregivers in their home environment. This deficient practice was for 1 of 1 resident reviewed for dignity (Resident #19). Findings Included: Resident #19 was admitted to the facility on [DATE] with diagnoses which included dementia. Resident #19's Minimum Data Set assessment dated [DATE] and 10/04/24 specified the resident's cognition was severely impaired and she had physical behavioral symptoms directed toward others on 4-6 days per week but less than daily. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe environment in the 700-hall by scrubbing floors with a scrubber that had a broken squeegee attachment which prevented excess water from being removed from the floor, leaving puddles of water behind, and failed to post wet floor signs on the wet 700 hallway floor that was wet and puddled with water left by the scrubber while staff were present on (2) of (4) days of the survey.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to record an opened date on two insulin pens that had shortened expiration dates. This was observed on 1 of 3 medication carts (200/300 hall medication cart) reviewed for medication storage.

Inspectors wroteBased on record review, and staff interviews the facility failed to accurately document on the Medication Administration Record (MAR) the administration of a narcotic pain medication (Hydrocodone-Acetaminophen oral tablet 5-325 milligrams). This occurred for 1 of 1 resident (Resident #20) reviewed for medication administration.

Inspectors wroteBased on record review, Deputy Officer interview, and staff interviews, the facility failed to follow their abuse policy and procedure in the areas of reporting and investigating in response to an allegation of abuse when a Deputy Officer arrived at the facility and informed the Administrator and Director of Nursing (DON) of an anonymous allegation of abuse involving an unnamed resident on the 700 hall being roughed up. This deficient practice was for 1 of 5 abuse allegations reviewed and had the potential to affect all facility residents.

Inspectors wrote2) An observation of a medication cart stored on the 700 hall was noted to be unlocked and unattended on 02/26/23 at 10:08 AM. The medication cart was noted to be facing the hallway where 3 alert residents propelling themselves in wheelchairs were noted to be passing by the unsecured medication cart. The cart was left unattended and unlocked for 3 minutes. An interview was conducted with Nurse #9 on 02/06/23 at 10:11 AM. Nurse #9 stated she would not normally leave the medication cart unlocked and had forgotten to lock it before she walked away from it. Nurse #9 stated it was important to make sure the medication carts were secured at all times when they were unattended for the safety of the residents. An interview was conducted with the Regional Clinical Director on 02/09/23 at 5:00 PM. [...]

Inspectors wroteBased on record review, observations and staff interviews the facility failed to remove expired food items stored for use and failed to label and date leftover food for 2 of 3 nourishment rooms (South Station and 400 Hall nourishment rooms). This practice had the potential to affect the food served to the residents.

Inspectors wroteBased on observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following a recertification survey on 1/4/22, a complaint investigation on 7/29/22, a focused infection control survey on 2/17/21 and a recertification survey on 3/5/20. This was for 4 deficiencies that were originally cited in the areas of notification of changes, quality of care, label/store drugs and biologicals and food storage and were subsequently recited on the current recertification and complaint investigation on 2/9/23. The continued failure during five federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance program.

Inspectors wroteBased on observations, record review, staff, Physician and Nurse Practitioner interviews the facility failed to notify the Physician or Nurse Practitioner to discontinue an NPO (nothing by mouth) order and to resume medications following notification that a surgical procedure had been rescheduled for a later date for 1 of 1 resident reviewed. (Resident #66).

Inspectors wroteBased on observations and staff interviews the facility failed to maintain walls in resident rooms and resident care area hallways in good repair and failed to repair or replace torn or stained linoleum and a threshold in resident bathrooms. This was for 9 of 18 resident rooms and 3 of 3 hallways reviewed for homelike environment (Rooms 201, 206, 207, 305, 306, 605, 607, 609, the 200 and 300 hallways and wall on the hallway in front of the the North Side nurses station area).

Inspectors wroteBased on observations, record review, staff, Physician and Nurse Practitioner interviews the facility failed to discontinue an NPO (nothing by mouth) order and resume medications following notification of a cancelled procedure resulting in a resident missing two doses of an antiplatelet medication (Plavix) and not being served a breakfast meal for 1 of 1 resident reviewed. (Resident #66).

Inspectors wroteBased on observations, record review, staff and Nurse Practitioner interviews the facility failed to implement new wound treatments orders prescribed by the wound care physician for 1 of 3 residents (Resident #62) reviewed for wound care.

Inspectors wroteBased on record review, staff, Nurse Practitioner and Physician interviews the facility failed to hold a blood pressure medication as ordered by the physician for 1 of 5 residents (Resident #66) reviewed for unnecessary medications.

Inspectors wroteBased on record review, resident and staff interviews the facility failed to honor food preferences for 1 of 2 residents (Resident #36) reviewed for food preferences.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code pain assessments on the Minimum Data Set (MDS) quarterly assessments for 2 of 18 residents (Resident #30 and Resident #55) reviewed.