Autumn Care of Madison

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF697Feb 23, 2023

  Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 28 residents in the survey sample, Resident # 49 (R49). The findings include: For (R49) the facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medications, hydromorphone (1) and Tylenol (2) and failed to clarify the physician's orders for the use of the PRN pain medications. (R49) was admitted to the facility with a diagnosis that included but was not limited to chronic pain. […]

• No harm, potential for more than minimal, patternF812Sep 16, 2021

  Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in the kitchen in accordance with professional standards for food service safety. The facility failed to properly dispose of dry goods that were past their expiration date, dispose of milk past it expiration date and date/label refrigerated juice not stored in it's original container. The findings include: On [DATE] at approximately 11:00 a.m., an observation of the facility's kitchen was conducted. Observation of the kitchen's dry storage area revealed an opened 24 ounce bag of french fried onions approximately three-quarters full with no open date on the package and a manufacturer's date on the package documenting Best used by 19:35 Jun (June) 24 2021. […]

• No harm, potential for more than minimal, isolatedF759Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of three errors occurred out of 31 opportunities for error due to residents not receiving their medication for two residents (Resident (R)19 and R84) out of six residents observed for medication administration. In addition, one of six residents (R27) received a partial dose of medication. The facility medication error rate was 9.68%. This failure had the potential to affect the accurate dosing of medication administered to the residents and for residents not to receive the full beneficial effects of the prescribed medications.Findings include:1. […]

• No harm, potential for more than minimal, isolatedF580Feb 5, 2025

  Based on staff interview and clinical record review, it was determined the facility staff failed to notify the physician and the responsible party of changes in condition for one of four residents in the survey sample, Resident # 3. The findings include: For Resident #3, the facility staff failed to notify the responsible party of a bruise on 12/19/24 and a fall on 12/25/24. The nurse's note dated 12/19/24 at 6:47 p.m. documented, Hospice CNA (certified nursing assistant) reported to this speaker that resident has bruising to R. (right) buttock. There is no documentation the physician or responsible party were notified of the bruise. The nurse's note dated 12/25/24 at 6:47 p.m. […]

• No harm, potential for more than minimal, isolatedF842Feb 5, 2025

  Based on staff interview and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of four residents in the survey sample, Resident #1. The findings include: Resident #1 was admitted to the facility on [DATE]. The resident was transferred to the hospital on 6/29/24 and did not return to the facility after her stay in the hospital. Resident was transferred elsewhere. Review of the clinical record revealed documented a physician note dated, 7/23/24, documented in part, Patient seen and evaluated for continuity of necessity of rehabilitation stay/skilled nursing/medication order review. Nurses' notes/vitals reviewed in PCC (initials of computer program), discussed patient status/progress with nursing staff. […]