Myrtles Nursing Center, LLC

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement its abuse prevention and investigation policy when Licensed Practical Nurse (LPN) #1 and Certified Nurse Aide (CNA) #1 witnessed Registered Nurse (RN) #1 attempting to prevent Resident #2 from bringing cigarettes into the facility and did not report the incident to the Administrator for one (1) of four (4) sampled residents (Resident #2).

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure infection control measures were followed to prevent the possible spread of infection as evidenced by, not following enhanced barrier precautions, improper hand hygiene and glove changes and allowing a urinary catheter bag to touch the floor for three (3) of (19) sampled residents. (Resident #9, Resident #36, and Resident #68) Findings Include: A review of the facility's policy titled Infection Control, revised on 04/21, revealed The facility will maintain an Infection Control Program, designed to provide a safe, sanitary, and comfortable environment where residents reside with minimal exposure to the development and transmission of disease and infection . Handwashing is the most to effective means of infection prevention . [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide the Resident, or the Resident Representative (RR), written notification of the bed hold policy at the time of transfer for one (1) of 19 sampled residents. (Resident #60) Findings Include: A review of the facility's policy tiled, Bed Hold Notice Upon Transfer/Leave, dated 12/23, revealed, Bed Hold Agreement . If bed-hold due to hospital transfer or therapeutic leave becomes necessary, the facility will notify the resident or resident's representative of the bed-hold option . A review of the Progress Notes, dated 7/21/24 for Resident #60, revealed that the resident was transferred to the local hospital at 6:13 PM per local ambulance, due to bleeding from the dialysis shunt. [...]

Inspectors wroteBased on staff interviews, record reviews, and facility policy review, the facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for one (1) of 19 residents reviewed. (Resident #77). Findings Include: A review of the facility's policy titled, Resident Assessment, with the revision date of 09/19, revealed, An assessment will be completed on each resident utilizing the MDS. The reason for assessment, schedule and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual. The Registered Nurse (RN) is responsible for verifying the completion of the assessment. The completed assessment guide the staff in identifying key information about the resident and serves as a basis for identifying resident specific issues and objectives in order to develop a care plan. [...]

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to submit discharge and annual Minimum Data Set (MDS) assessments in a timely manner for three (3) of (19) resident MDSs reviewed. (Resident #55, #60, and #77). Findings Include: A review of the facility's policy titled, Resident Assessment, with the revision date of 09/19, revealed, An assessment will be completed on each resident utilizing the MDS. The reason for assessment, schedule and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual. The Registered Nurse (RN) is responsible for verifying the completion of the assessment. The completed assessment guide the staff in identifying key information about the resident and serves as a basis for identifying resident specific issues and objectives in order to develop a care plan. [...]

Inspectors wroteBased on observations, staff interviews, record reviews, and facility policy review, the facility failed to implement residents' care plans for three (3) of (19) care plans reviewed. (Residents #9, #36, and #68) Findings Include: A review of the facility's policy titled Care Plan Process, with the latest revision date of 08/17, revealed: Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision, and continence). The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care . [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure medications were secured in a locked storage area and available to only authorized personnel when medications were left at a resident's bedside for one (1) of (19) sampled residents. (Resident # 47) Findings Include: A review of the facility's policy titled Medication Storage, with revision date of 11/17, revealed .Medication storage shall meet all applicable federal, state, and local guidelines . At 10:30 AM on 09/30/24, during the initial tour, Resident #47's door was open, but the resident was not in the room. An observation revealed two (2) medications in boxes, including nasal spray and an inhaler, on the bedside table. [...]

Inspectors wroteBased on interviews, observations, record review, and facility policy review, the facility failed to provide a resident with a physician-ordered diet of chopped bite-size meats for one (1) of (19) sampled residents. Resident #1. Findings Include: A review of the facility's policy titled Dental Soft Mechanical Soft Diet, revised 2016, revealed . The diet should be individualized to meet a particular patient's needs . meats may be ground or diced based on the individual's tolerance . On 09/30/24 at 11:40 AM, during an interview, Resident #1 stated that her meat was supposed to be served in bite-size pieces, but it was often pureed. She expressed that she disliked pureed meat and would refuse to eat it. Resident #1 further noted that her meal ticket specified bite-size meat, but it was not consistently provided. [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, plan of correction review, and facility policy review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) Program, as evidenced by one (1) re-cited deficiency originally cited in February 2023 on an annual recertification survey for (1) of two (2) annual recertification surveys reviewed. Findings Include: A review of the facility's policy titled Preface - QAPI, dated 11/22, revealed: Our residents are the primary concern of this facility. This facility is committed to providing the highest quality of life supported by quality care for the aged and convalescent resident. [...]

Inspectors wroteBased on staff and Resident Representative (RR) interviews, record review, and facility policy, the facility failed to protect private health information for one (1) of six (6) sampled residents. (Resident #6) Findings Include: A review of the facility's policy titled, Confidentiality of Resident Information, with a revision date of 05/18 revealed, Policy: The health record is the property of the health care facility and is maintained to serve the resident, the health care providers, and the institution in accordance with legal regulatory requirements. All resident care information shall be regarded as confidential and available only to authorized users . On 6/26/24 at 10:30 AM, during a telephone interview with the RR for Resident #3, she stated that on 6/18/24, she went to the facility to retrieve copies of her brother's medical records from the facility Administrator. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure staff followed the facility's infection control guidelines while disinfecting a glucose meter after use for one (1) of one (1) observations of disinfecting glucose meters. (Resident #67) Additionally, the facility failed to ensure staff followed appropriate hand washing protocol while performing wound care for one (1) of one (1) wound care observations. (Resident 23). Resident #67 Review of the facility's policy, Infection Control and Isolation, with a revision date of 01/12, revealed, Policy: The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection . [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent cross contamination and trauma to the bladder for one (1) of two (2) catheter care observations for Resident #3.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to prevent possible spread of infection during catheter care by not providing a barrier, washing hands or changing gloves for one (1) of two (2) catheter care observations, for Resident #3.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide privacy during the administration of enteral medication for Resident #64 and for continuous enteral feedings for Resident #72; for two (2) of six (6) residents observed for privacy during medication pass and for residents with enteral feedings.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) related to discharge for one (1) of 24 resident MDS assessments reviewed, Resident #86.

Inspectors wroteBased on facility policy review, staff interview, and record review, the facility failed to develop a care plan related to the diagnosis of Depression for one (1) of 24 resident care plans reviewed, Resident #70.

Inspectors wroteBased on facility policy review, staff interview, and record review, the facility failed to revise the comprehensive care plan related to an antipsychotic medication for one (1) of five (5) residents reviewed for unnecessary medication review, Resident #34; and, failed to revise the comprehensive care plan related to catheter care for one (1) of four (4) residents care plans reviewed for catheter care, Resident #3.

Inspectors wroteBased on facility policy review, record review, and staff interview, the facility failed to complete an accurate Preadmission Screening (PAS) upon admission for three (3) of three (3) resident PASs reviewed, Resident #78, Resident #15, and Resident #23.