Autumn Care of Raeford

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Sep 29, 2025

  Based on record reviews and interviews with staff, Responsible Party (RP), Emergency Medical Services (EMS) personnel, and the Medical Director, the facility failed to accurately transcribe necessary information from the FL2 (a medical form completed by a physician to document a patient's medical condition, necessary care, and recommended level of care) to ensure staff monitored a resident's blood glucose (sugar) and administered insulin or sought clarification from a medical provider for a resident with diabetes. […]

• Immediate jeopardy, isolatedF600Apr 16, 2024

  Based on record review, observation, the facility's surveillance video, and interviews with staff and law enforcement, the facility failed to protect a cognitively impaired female resident's (Resident #1) right to be free from sexual abuse by a male visitor. On 03/28/24, the Visitor was at the facility visiting his family member (Resident #2) in a common area of the facility when he left that area and went to her (Resident #2's) semi-private room on the secured dementia unit where she resided with Resident #1. Resident #1 was in her bed when the Visitor was observed by Nursing Assistant (NA) #1 as he leaned over Resident #1 with his back to the door. NA #1 asked what he was doing and the Visitor turned around and adjusted the waist of his pants. […]

• No harm, potential for more than minimal, isolatedF759Feb 26, 2026

  Based on observations, record reviews, staff, Resident and Physician interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 30 opportunities, resulting in a medication error rate of 6.67% for 1 of 4 residents observed during the medication administration (Resident #116).The findings included:Review of Resident #116's physician orders revealed an order for aspirin, 81 milligrams (mg) chewable tablet, once a day for deep vein thrombosis (DVT) prevention dated 08/28/2025 and an order for polyethylene glycol 3350 powder; 17 grams, 1 scoop daily for constipation dated 08/28/2025. Review of Resident #116's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 was cognitively intact. […]

• No harm, potential for more than minimal, isolatedF688Oct 18, 2024

  Based on observation, record review and staff interviews, the facility failed to apply left hand splint as ordered for 1 of 3 sampled residents with limited range of motion/contractures (Resident #61). Findings included: Resident #61 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, dementia, need for assistance with personal care, reduced mobility, lack of coordination, and contracture of muscle, multiple sites. Resident #61's quarterly Minimum Data Set Assessment (MDS) dated [DATE] coded the resident as moderately cognitively impaired. He was coded as dependent with personal hygiene, bathing and toileting. He required setup/clean-up assistance with eating and oral hygiene. […]

• No harm, potential for more than minimal, isolatedF641Apr 28, 2022

  Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents (Resident # 31) reviewed for PASRR. Findings included: Resident #31 was admitted to the facility on [DATE] and most recently readmitted on [DATE] after hospitalization with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review indicated Resident #31 had a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification dated 11/12/15. […]