Inspection Reports for
Myers Park Nursing Center

The complaint investigation was triggered by allegations of resident-to-resident physical abuse involving Resident #64 throwing Resident #84 to the floor causing injury, failure to protect residents from abuse, failure to report abuse timely, failure to supervise wandering residents leading to unsafe wandering, and unsafe transportation practices resulting in a resident fall. Immediate jeopardy was identified on 01/27/25 and remained ongoing at the time of the survey.

The facility failed to protect residents from physical abuse by another resident, failed to immediately report abuse allegations to the Administrator, failed to implement adequate supervision and monitoring for residents at risk of wandering, failed to update care plans timely, and failed to ensure safe transportation of a resident resulting in a fall. Immediate jeopardy was identified related to resident-to-resident abuse and inadequate supervision of a wandering resident.

The complaint investigation was substantiated with findings of immediate jeopardy related to resident-to-resident abuse by Resident #64 and unsafe transport of Resident #336. Additional deficiencies were found related to care plan updates, food safety, supervision, and reporting.

The facility was found to have multiple deficiencies including failure to protect residents from abuse, failure to notify physicians of incidents, failure to maintain wheelchairs and window blinds, failure to update care plans, failure to ensure safe transport of residents, failure to maintain nourishment rooms and food safety, and failure to submit required staffing data. Immediate jeopardy was identified related to resident-to-resident abuse and unsafe transport practices.

The complaint investigation was substantiated. Immediate jeopardy was identified due to failure to update MOST form and failure to complete neurological assessments after a fall. Immediate jeopardy was removed after corrective actions were implemented.

The facility failed to update a resident's Medical Orders for Scope of Treatment (MOST) form to reflect Do Not Intubate wishes, resulting in the resident being intubated against his and his responsible party's wishes. Additionally, the facility failed to complete ongoing neurological assessments after an unwitnessed fall, leading to delayed recognition of a life-threatening subdural hematoma. Immediate jeopardy was identified and later removed after the facility implemented corrective actions including staff education and monitoring systems.

The complaint investigation involved an allegation of resident-to-resident abuse resulting in physical injury to Resident #3. The facility's investigation did not substantiate the abuse allegation due to lack of witnesses, but failed to notify Adult Protective Services as required. The incident was unwitnessed and involved bruising, bleeding, and a nasal fracture. Staff interviews revealed delays and failures in reporting and investigating the incident as abuse.

The facility failed to report and investigate an injury of unknown origin to Resident #3 in a timely manner. Resident #3 sustained bilateral periorbital ecchymosis, a nasal fracture, and left wrist swelling after an altercation with another resident. The facility did not notify Adult Protective Services and did not consider the incident as abuse initially, delaying proper investigation and reporting.

The investigation was triggered by a complaint regarding Resident #1 leaving the facility without staff knowledge or supervision. The resident was found safe but disoriented at a behavioral health center. The complaint was substantiated with findings of inadequate supervision and failure to follow elopement protocols promptly.

The facility failed to monitor Resident #1, who left the facility without notifying staff and walked to a convenience store. Despite being a supervised smoker due to past safety concerns, Resident #1 was able to leave alone, became disoriented, and was found at a behavioral health center before being returned by police. The facility initiated elopement protocols and placed the resident on 1:1 supervision after the incident.

The complaint investigation was triggered by a fall incident on 5/22/24 involving Resident #12 who fell from her wheelchair on the facility's transportation van while unsupervised. Immediate jeopardy was identified due to failure to supervise and improper handling of the fall. Immediate jeopardy was removed on 7/19/24 after corrective actions were implemented.

The facility failed to properly supervise Resident #12 during transportation, resulting in a fall with injury, and failed to discontinue aspirin as recommended by the hospital for Resident #12. Additionally, the facility failed to supervise Resident #38, a supervised smoker, who smoked in her room unsupervised. Immediate jeopardy was identified related to the fall incident but was removed after corrective actions.

The complaint investigation was triggered by incidents including a resident fall on a transportation van due to lack of supervision, failure to follow physician orders for medication and feeding tube care, inadequate dietary food preparation, and unsanitary dumpster conditions. Immediate jeopardy was identified related to the transportation fall but was removed after corrective actions.

The facility failed to properly supervise residents during transportation and smoking times, failed to follow physician orders for medication discontinuation and feeding tube flushes, failed to provide mechanically altered diets consistent with physician orders, and failed to maintain sanitary conditions around dumpsters. Immediate jeopardy was identified related to unsupervised resident fall during transportation but was removed after corrective actions.

The facility was found deficient in multiple areas including failure to provide dignified dining experiences, inaccurate medical records, inadequate care planning, improper food storage and preparation, failure to provide appropriate foot and nail care, failure to maintain catheter care standards, and failure to maintain effective quality assurance processes. Several deficiencies were repeat citations from prior surveys.

The visit was complaint-related, triggered by infection control issues cited in a prior complaint survey dated 12/11/2020. The facility's failure to correct these deficiencies was substantiated by observations during the 12/18/2023 survey.

The facility failed to implement proper hand hygiene procedures during wound care treatments for two of three residents reviewed, including failure to sanitize hands between glove changes. The facility's QAA Committee showed a pattern of inability to sustain effective infection control interventions over multiple surveys.

The complaint investigation was triggered by Resident #1 leaving the facility without signing out and being missing for several days. The facility was unaware of his whereabouts until he returned. The investigation included interviews with Resident #1, family, medical and nursing staff, and review of medical records and facility policies. The complaint was substantiated with findings of failure to identify elopement risk and inadequate supervision.

The facility failed to identify the risk for elopement for Resident #1, who left the facility without signing out and was missing for several days. Staff were unaware of his whereabouts during this time. Upon return, Resident #1 was assessed and found to be at baseline with no signs of injury or substance abuse. The facility also failed to maintain effective Quality Assessment and Assurance (QAA) processes to monitor and sustain corrective actions related to accident hazards and supervision.

The complaint investigation revealed immediate jeopardy conditions related to resident safety. Resident #1 left the facility unsupervised in a motorized wheelchair and was struck by a garbage truck, sustaining multiple fractures and requiring ICU admission. Resident #2 sprayed an unlabeled chemical on his wheelchair and suffered chemical burns requiring hospitalization. Immediate jeopardy was removed on 10/22/2023 after the facility implemented corrective actions.

The facility failed to assess and educate a resident with dementia and traumatic brain injury on the safe use of a motorized wheelchair, resulting in a serious accident causing multiple fractures and hospitalization. Another resident suffered chemical burns from an unlabeled cleaning solution. The facility also failed to maintain effective quality assurance processes to prevent accidents and ensure resident safety.

The complaint investigation found that Resident #2, known for physically aggressive behavior, hit Resident #1 in the eye causing a traumatic subdural hematoma. The facility failed to maintain adequate supervision and safety interventions after Resident #2's return from the hospital. The immediate jeopardy began on 03/17/23 and was removed on 04/13/23 after corrective actions were implemented.

The facility failed to implement adequate safety measures to protect residents from Resident #2, who had a history of aggressive behaviors. This failure resulted in Resident #1 sustaining a traumatic subdural hematoma after being hit in the eye. Immediate jeopardy was identified but later removed after the facility implemented corrective actions including one-on-one supervision and staff education.

The facility was found deficient in multiple areas including failure to maintain resident dignity and provide clean clothing, failure to accommodate resident needs such as accessible call lights, failure to allow a resident to smoke unsupervised despite assessment, failure to maintain a clean and safe environment including shower rooms and kitchen, failure to protect residents from abuse and neglect including a staff to resident physical abuse incident, failure to prevent residents from exiting the facility unsupervised leading to an intruder entering and vandalizing the facility, failure to maintain medication storage and expiration protocols, and failure to maintain effective quality assurance and administrative oversight.