Autumn Care of Norfolk

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 20, 2026

  Based on record review, interviews, and policy review, the facility failed to: 1.) appropriately assess a resident and identify and implement interventions related to wandering and elopement risk for one of two residents (Resident (R) 10) reviewed for elopement out of a total sample of 47. As a result, R10, who had been assessed as an elopement risk prior to a hospital discharge but was not assessed at risk on readmission, exited the facility without staff knowledge 12 days after readmission and sustained a subarachnoid hemorrhage, a severe head injury. […]

• No harm, potential for more than minimal, widespreadF921Aug 20, 2026

  Based on observations and interviews, the facility failed to lock the front doors to prevent unauthorized individuals from entering the facility and residents from exiting the facility without staff's knowledge during the night shift. The facility also failed to store items including cleaners, air fresheners, disposable razors, shaving cream, foot spray, baby oil, and staff food where it was not accessible to residents. This failure to maintain a safe environment had the potential to place the 114 residents who resided in the facility at risk for elopement, injury, ingestion of hazardous substances, and exposure to unsafe environmental conditions. […]

• No harm, potential for more than minimal, patternF580Jan 13, 2023

  Based on resident interview, staff interviews, and clinical record review, the facility staff failed to notify the resident, the Physician and/or Practitioner that the scheduled medications were not administered as ordered for one of 43 residents (Resident #149) in the survey sample. The findings included: The scheduled intravenous (IV) antibiotic Daptomycin Solution Reconstituted was not administered on 1/6/23, 1/7/23, 1/8/23 and 1/9/23. Resident #149 was originally admitted to the facility 1/6/23 after an acute care hospital stay. The resident had never been discharged from the facility. The resident's diagnoses included diabetes, osteomyelitis of the left foot resulting in a partial resection of the remnant of the left second toe, and amputation of toes number 3-5 of the left foot. […]

• No harm, potential for more than minimal, patternF636Jan 13, 2023

  Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to conduct a comprehensive Minimum Data Set (MDS) assessment within 14 calendar days after admission, for three of 43 residents (Resident #152, #153, and #200), in the survey sample. The findings included: 1. The facility staff failed to complete an admission MDS assessment for Resident #152 within 14 calendar days. Resident #152 was admitted to the facility 12/28/22 after an acute care hospital stay. The resident had never been discharged from the facility. The resident's diagnosis included multiple myleoma. Upon review of the MDS assessment on 1/11/23 under information, the assessment was noted to be incomplete. […]

• No harm, potential for more than minimal, patternF755Jan 13, 2023

  Based on observations, clinical record review, staff and resident interviews and facility document review, the facility staff failed to provide pharmaceutical services that assured medications were acquired timely to meet the needs of one of 43 residents in the survey sample, Resident #149. The findings included: The facility staff failed to procure the intravenous (IV) antibiotic Daptomycin Solution Reconstituted timely to prevent Resident #149 from missing dosages for a Complicated skin and skin structure infections (cSSSI). Resident #149 was originally admitted to the facility 1/6/23 after an acute care hospital stay. The resident had never been discharged from the facility. […]