Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Myrtles Nursing Center, Llc during CMS and state inspections, most recent first.
Staff failed to follow abuse prevention and investigation policy when a resident was physically blocked by an RN during an attempt to bring cigarettes into the facility. Both an LPN and a CNA witnessed the incident but did not report it to facility leadership, resulting in the event not being investigated as required by policy.
A long-term care facility failed to follow infection control measures, including improper handling of urinary catheter bags, inadequate use of enhanced barrier precautions, and poor hand hygiene. A resident's catheter bag was placed on the floor, another resident received care without proper gown use and glove changes, and a nurse did not follow protocols during PEG tube care. These actions were confirmed by staff and posed infection risks to the residents involved.
A resident was not provided with written notification of the bed hold policy upon transfer to a hospital, as required by the facility's policy. The Accounts Manager admitted to forgetting to provide the necessary documentation, which is crucial for residents on Medicare to understand their financial responsibilities during hospitalization. The Licensed Nursing Home Administrator expects staff to adhere to the facility's policies.
A resident's annual MDS assessment was not completed within the required timeframe, as the ARD was set more than 366 days after the admission MDS and more than 92 days from the last quarterly assessment. The completion date exceeded the 14-day requirement after the ARD. Staff interviews revealed errors in the assessment process, and the facility administrator was unaware of the late assessment.
The facility failed to submit discharge and annual MDS assessments on time for three residents. A resident's discharge MDS was completed late, another's was still in progress after a hospital transfer, and a third's annual MDS was submitted beyond the required timeframe. Staff interviews revealed a lack of awareness and oversight, with the LPN and RN confirming the late submissions. The administrator was unaware of these issues, despite expectations for timely and accurate submissions according to policy.
The facility failed to implement care plans for three residents, resulting in deficiencies. A resident with a suprapubic catheter lacked a securement device, causing the catheter to pull on the skin. Another resident with an indwelling catheter did not receive care with the required enhanced barrier precautions, as a CNA only wore gloves instead of both gown and gloves. Similarly, a resident with a PEG tube did not receive care with the necessary gown, as an RN was not trained in enhanced barrier precautions.
A resident's medications, including a nasal spray and inhaler, were left unsecured on a bedside table, contrary to facility policy requiring locked storage. The LPN admitted to the oversight, and the DON confirmed no orders for self-administration or bedside storage existed for the cognitively intact resident with COPD and Allergic Rhinitis.
A resident with a physician-ordered diet of chopped bite-size meats was often served shredded or pureed meat, contrary to the specified diet. Despite the resident's cognitive intactness and clear meal ticket instructions, the dietary staff did not consistently follow the diet orders. Interviews with the Dietary Manager and LNHA confirmed the expectation for adherence to diet orders, highlighting a deficiency in meal preparation.
The facility failed to maintain compliance with hand hygiene protocols during PEG tube and catheter care, despite having a plan of correction in place. This deficiency was re-cited due to high staff turnover, particularly among the DONs, which hindered effective staff training and consistent policy implementation.
A breach of confidentiality occurred when a resident's private health information was mistakenly given to another resident's representative. The facility's Administrator confirmed the error, which involved the disclosure of a Dialysis Transfer Summary. The affected resident had End Stage Renal Disease and Type 2 Diabetes Mellitus.
Failure to Report and Investigate Resident Incident Involving Staff
Penalty
Summary
Facility staff failed to implement the abuse prevention and investigation policy when an incident occurred involving a resident and a registered nurse. The incident involved the nurse physically blocking the resident from entering the building and attempting to take a bag containing cigarettes from him, resulting in a tussle at the doorway and the resident's arm becoming caught. The resident, who was cognitively intact and had a history of hemiplegia and hemiparesis following cerebral infarction, reported the incident during an interview. Two staff members, an LPN and a CNA, witnessed the event but did not document or report it to facility leadership as required by policy. The facility's policy mandates immediate reporting of any incident involving suspicion or allegation of mistreatment, exploitation, neglect, or abuse to the Administrator. Despite this, neither the LPN nor the CNA notified the Director of Nursing, Assistant Director of Nursing, or Administrator about the incident. The Director of Nursing and Administrator both confirmed they were not informed and stated that an investigation would have been initiated had they been notified. The failure to report and investigate the incident constituted a breach of the facility's abuse prevention and investigation policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control measures, as evidenced by improper handling of urinary catheter bags, inadequate use of enhanced barrier precautions, and poor hand hygiene practices. For Resident #9, the catheter drainage bag was placed on the floor multiple times during catheter care, which was acknowledged by the staff as a potential cause for urinary tract infections and cross-contamination. The resident had a history of infection and inflammatory reaction due to a cystostomy catheter and was cognitively intact. Resident #36's care was compromised when a CNA did not wear a gown as required by enhanced barrier precautions and failed to change gloves after cleaning a bowel movement, continuing care with the same gloves. This resident had a diagnosis of urinary retention and moderate cognitive impairment. The failure to follow proper infection control protocols was confirmed by the CNA involved. For Resident #68, a nurse did not wear a gown or perform hand hygiene between glove changes during PEG tube care, despite signage indicating the need for enhanced barrier precautions. The nurse admitted to not following the facility's infection control protocols, which posed a risk of infection to the resident. This resident had severe cognitive impairment and a history of dysphagia following a stroke.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to a resident or their representative at the time of transfer to a hospital. This deficiency was identified for one of the 19 sampled residents, specifically Resident #60, who was transferred to a local hospital due to bleeding from a dialysis shunt. The facility's policy, dated December 2023, requires that residents or their representatives be notified of the bed hold option when a transfer or therapeutic leave becomes necessary. During an interview, the Accounts Manager admitted to forgetting to provide the bed hold letter to Resident #60 during their hospitalization. The Accounts Manager explained that residents must receive both the bed hold and transfer letters each time they are hospitalized, as Medicare does not cover both the hospital and the facility simultaneously. The Licensed Nursing Home Administrator stated that staff are expected to follow the facility's policies and procedures regarding bed hold notifications. Resident #60 was admitted to the facility in April 2024 with a diagnosis of End Stage Renal Disease.
Failure to Complete Timely Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for one of the residents reviewed. The facility's policy requires that an assessment be completed on each resident using the MDS, following the guidance of the Resident Assessment Instrument (RAI) Manual. The Registered Nurse (RN) is responsible for verifying the completion of the assessment. However, for the resident in question, the annual MDS assessment was not completed within the required timeframe. The assessment reference date (ARD) for the annual MDS was set more than 366 days after the admission MDS and more than 92 days from the last quarterly assessment, and the completion date was more than 14 days after the ARD. Interviews with facility staff revealed that the MDS nurse was informed by corporate nurses that there was no such thing as a too early assessment. However, in August, it was realized that too many quarterly MDS assessments had been completed for the resident, leading to an error and the need to redo the assessment as an annual assessment. The RN confirmed that the annual assessment was completed late. The facility administrator was unaware of the late assessment and emphasized the importance of following the facility's policy and the RAI manual to ensure timely and accurate MDS assessments.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to submit discharge and annual Minimum Data Set (MDS) assessments in a timely manner for three residents. According to the facility's policy and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. However, the facility did not adhere to these guidelines. Resident #55 was discharged with a return not anticipated, but the discharge MDS was completed significantly late. Resident #60 was transferred to the hospital, and the discharge MDS was still in progress and not completed. Resident #77's annual MDS was also submitted well beyond the required timeframe. Interviews with facility staff revealed a lack of awareness and oversight regarding the timely submission of MDS assessments. The Licensed Practical Nurse (LPN) responsible for MDS assessments acknowledged the oversight and confirmed the late submissions. The Registered Nurse (RN) also confirmed the late submissions for Residents #55 and #77. The facility administrator was unaware of the missed and late assessments, emphasizing the expectation for staff to follow the facility's policy and the RAI manual for timely and accurate submissions. These deficiencies highlight a failure in the facility's processes to ensure timely MDS submissions, which are critical for providing appropriate resident care and ensuring accurate reimbursement for services.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for three residents, leading to deficiencies in care. For Resident #9, the care plan required a securement device for a suprapubic catheter to prevent pulling on the skin. However, an observation revealed that the catheter was stretched and pulling taut on the skin, and no securement device was in place. A CNA confirmed the absence of the device, which was required by the care plan. Resident #9 was admitted with a diagnosis of urinary retention. For Resident #36, the care plan included enhanced barrier precautions during high-contact activities due to an indwelling catheter. Despite signage indicating the need for both gown and gloves, a CNA only wore gloves during catheter care. The CNA acknowledged the requirement for a gown and confirmed her training in enhanced barrier protocols. Resident #36 was admitted with paraplegia. Similarly, Resident #68's care plan required enhanced barrier precautions during PEG tube care. An RN performed the care without wearing a gown, despite signage indicating its necessity. The RN admitted to not being trained in enhanced barrier precautions. Resident #68 was admitted with dysphagia following a cerebrovascular accident.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were secured in a locked storage area and were only accessible to authorized personnel. During an initial tour, it was observed that a resident's door was open, and two medications, including a nasal spray and an inhaler, were left on the bedside table while the resident was not in the room. Later, the resident confirmed that the nurse had left the medications there earlier that morning, which was a recurring issue. The Licensed Practical Nurse (LPN) admitted to accidentally leaving the medications in the room, acknowledging that medications should not be left in residents' rooms. The Director of Nursing (DON) was unaware of the incident and confirmed that medications should only be stored on the medication cart, with no orders for self-administration or bedside storage for the resident. The resident, who was cognitively intact, had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Allergic Rhinitis. The facility's policy on medication storage required compliance with federal, state, and local guidelines, which was not adhered to in this instance.
Failure to Provide Physician-Ordered Diet
Penalty
Summary
The facility failed to provide a resident with a physician-ordered diet of chopped bite-size meats, as evidenced by multiple instances where the resident received shredded or pureed meat instead. The resident, who was cognitively intact with a BIMS score of 14, expressed dissatisfaction with the consistency of the meat, stating a preference for bite-size pieces and a refusal to eat shredded meat. The resident's meal ticket and diet order specified bite-size meats, yet observations on different occasions revealed discrepancies in the meal preparation. Interviews with the Dietary Manager and the Licensed Nursing Home Administrator confirmed that the dietary staff were expected to follow the diet orders exactly as written. Despite this expectation, the resident's meals did not consistently meet the specified requirements. The resident, admitted to the facility with diagnoses including Dyspnea and GERD, had a diet order for a mechanical soft texture with bite-sized meats, which was not adhered to, leading to the deficiency noted in the report.
Failure to Maintain Hand Hygiene Compliance
Penalty
Summary
The facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) Program, as evidenced by a re-cited deficiency related to hand hygiene during percutaneous endoscopic gastrostomy (PEG) tube and catheter care. This deficiency was originally cited in February 2023 during an annual recertification survey. Despite having a plan of correction (POC) in place, the facility did not maintain compliance with hand hygiene protocols, which was observed during a subsequent survey. The facility's policy emphasizes the importance of maintaining high-quality care and proper infection control practices, yet these standards were not consistently met. The ongoing issue with hand hygiene compliance was attributed to high staff turnover, particularly among the Directors of Nursing (DON). The facility had employed five different DONs over the past two years, which posed challenges in training staff effectively and ensuring consistent implementation of the hand hygiene policy. The current DON had only been in the role for six months, having previously served as the Assistant Director of Nursing (ADON). The Administrator acknowledged the difficulty in maintaining compliance due to these staffing challenges, despite the facility's efforts to address the deficiency through the POC.
Breach of Resident Confidentiality
Penalty
Summary
The facility failed to protect the private health information of one of its residents, resulting in a breach of confidentiality. During an interview, the Resident Representative (RR) for another resident reported that she received three pages of medical records belonging to a different resident while retrieving her brother's medical records from the facility. These records included a Dialysis Transfer Summary for the resident whose information was improperly disclosed. The facility's Administrator confirmed that she provided the RR with 1,300 pages of medical records for the intended resident and acknowledged that the facility is responsible for protecting residents' health records. However, she admitted that the RR must have accidentally received medical records that did not belong to her brother, indicating a lapse in the facility's procedures for safeguarding confidential information. The affected resident had been admitted to the facility with diagnoses including End Stage Renal Disease and Type 2 Diabetes Mellitus.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grove | 0.8 mi | ★★★★★ | 10 | 0 |
| Columbia Rehabilitation And Healthcare Center | 1.7 mi | ★★★★★ | 6 | 0 |
| Billdora Senior Care | 21.7 mi | ★★★★★ | 4 | 1 |
| Diversicare Of Tylertown | 22.1 mi | ★★★★★ | 4 | 0 |
| Jefferson Davis Community Hospital Ecf | 23.5 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.