Autumn Care of Myrtle Grove

In the surveyor’s words

From the most serious findings on record at Autumn Care of Myrtle Grove, in the surveyor’s own words.

• Immediate jeopardy, patternF760Jul 29, 2022

  Based on record review, Nurse Practitioner, and staff interviews, the facility failed to review the hospital discharge medication summary for a newly admitted resident (Resident #1) resulting in the failure to transcribe and administer an anticoagulant (blood thinner) medication listed on the discharge medication summary. [MEDICATION(S)] (anticoagulant) was not administered from 05/27/22 through 06/14/22 (18 days). Resident #1 developed swelling to the left arm, was sent to the hospital, and was diagnosed with a blood clot. […]

• Immediate jeopardy, isolatedF580Apr 24, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF693Apr 24, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF726Apr 24, 2025

  Based 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). […]

• Immediate jeopardy, isolatedF600Nov 1, 2024

  Based 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. […]