Autumn Care Of Biscoe

In the surveyor’s words

From the most serious findings on record at Autumn Care Of Biscoe, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 31, 2022

  Based on observations, staff interviews, Medical Director interview, and record review, the facility failed to secure Resident #82 in a sit to stand lift per manufacturer's instructions and failed to provide a safe transfer which resulted in a fall. This was for 1 of 8 residents reviewed for accident hazards, supervision, and devices. Resident #82 sustained a left shoulder fracture. After a pulmonary evaluation, it was determined Resident #82's acute on chronic decline was due to her underlining severe Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), complicated by lung collapse likely due to decreased mobility from recent fall and from her baseline muscle weakness from prior stroke. […]

• Actual harm, isolatedF690Mar 20, 2024

  Based on record review, resident, Physician and staff interviews, the facility failed to act on a hospital discharge order for a nephrology follow up appointment for Resident #60 that resulted in her requiring antibiotics to treat UTIs on 5/26/23, 10/11/23, 10/28/23, 1/18/24 and 2/25/24. This was for 1 of 2 residents reviewed for urinary tract infections (UTIs). The findings included: Resident #60 was admitted on [DATE] with cumulative diagnoses of congestive heart failure and chronic kidney disease. Review of Resident #60's hospital discharge summary dated 3/13/23 included an order for a nephrology consult in 2-4 weeks. Resident #60 was care planned on 10/12/23 for current and/or a history of UTIs. Interventions included antibiotics as ordered. […]

• Actual harm, isolatedF689Oct 21, 2021

  Based on observations, staff, Physician and Responsible Party (RP) interviews and record review , the facility failed to prevent falls as evidenced by not ensuring call bell was within reach (Resident #175) and not ensuring a resident's wheelchair was safe for use (Resident #66). The facility also failed to analyze and identify the root cause of the falls and failed to implement effective interventions to prevent further falls (Residents #175). Resident ##175 sustained a left wrist fracture and Resident #66 sustained a right ankle sprain from the falls. This was evident for 2 of 5 sampled residents reviewed for accidents. The finding included: 1. Resident #175 was admitted on [DATE] with cumulative diagnoses of [CONDITION(S)], dementia and a history of falls. […]

• No harm, potential for more than minimal, widespreadF563Oct 21, 2021

  Based on record review, resident interviews, and staff interviews, the facility failed to follow the Centers for Medicare and Medicaid (CMS) visitation guidelines when they imposed a restricted visitation schedule for 1 of 2 residents reviewed for visitation (Resident # 73). This facility practice had the potential to impact all residents residing in the facility. Findings included: The facility's undated Visitation Guidance was reviewed and read in part: Compassionate care visits are always permitted Outdoor visitation is preferred over indoor Consideration should be given to how the total number of visitors in the facility may affect the ability to maintain infection prevention protocols (size of building and physical space). […]

• No harm, potential for more than minimal, patternF623Mar 13, 2025

  Based on record reviews and staff interviews, the facility failed to provide the resident and responsible party (RP), written notification of the reason for a hospital transfer for 4 of 4 residents reviewed for hospitalization (Residents #19, # 44, #61 and #4). The findings included: 1. Resident #19 was admitted to the facility on [DATE]. Resident #19's medical record revealed she was transferred to the hospital on [DATE] and 12/31/24 for mental status changes. There was no documentation that a written notice of transfer was provided to the resident and RP for the reason for the transfer. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 was cognitively intact. […]