Autumn Care of Salisbury

In the surveyor’s words

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

• Actual harm, isolatedF684Jul 10, 2023

  Based on record review and staff, Medical Director, Physician Assistant (PA) and Orthopedic Physician Assistant interviews the facility failed to follow a PA's order written on 05/03/23 to arrange for orthopedic follow up within 2 weeks for a resident. The resident was not seen until 05/31/23 and the Orthopedic PA noted drainage from the surgical wound and the staples were still in place and imbedded in the skin. The resident was sent to the hospital due to concern for a periprosthetic joint infection (infection around the hip prosthesis) and on 06/06/23 an incision and drainage was performed to the left hip in the operating room. This deficient practice occurred for 1 of 2 residents reviewed with a surgical wound (Resident #1). […]

• Actual harm, isolatedF600Apr 8, 2021

  Based on record reviews and staff interviews, the facility failed to protect a cognitively impaired resident from verbal and physical abuse from a staff member for 1 of 4 resident's reviewed for employee to resident abuse. Resident #1. The findings include: Resident #1 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Medicare 5 day Minimum Data Set, dated dated dated [DATE], Resident #1 was cognitively impaired, independent with transfers, required extensive assistance with bed mobility, and was independent with mobility in his room and on the unit. Review of Resident #1's care plan dated 1/13/21 revealed a goal for the resident to have no behaviors and to maintain behavioral manifestation to a minimum. […]

• No harm, potential for more than minimal, patternF812Apr 2, 2026

  Based on observations and staff interviews, the facility failed to store, label and date food in 1 of 1 freezer reviewed for safe food handling. During an observation conducted with the Dietary Manager, multiple food items were observed removed from their original packaging, placed in resealable plastic bags without labeling, and lacked open and/or expiration dates. Additionally, food items in original packaging were observed without opening or expiration dates. These findings had the potential to affect the safety and quality of food served to residents. […]

• No harm, potential for more than minimal, patternF921Apr 2, 2026

  Based on record review, observations, and staff interviews, the facility failed to secure cords from wall-mounted televisions which could cause a tripping hazard for 7 of 27 rooms (603,604, 605, 606, 607, 608, and 609) on 1 of 4 halls (600 hall).The findings included:The facility grievances were reviewed, and a grievance filed on 4/30/25 indicated that television cords from the wall-mounted televisions poised a tripping hazard.A purchase order form dated 5/5/25 indicated that ten (10) cord securement kits were approved on 5/5/25 by the former Administrator. […]

• No harm, potential for more than minimal, patternF812Mar 6, 2025

  Based on observation and staff interviews, the facility failed to label and date leftover food items, remove food items with signs of spoilage and not store staff food in 1 of 2 nourishment room refrigerators (the 600 Hall nourishment room); and failed to remove expired food stored for use in 1 of 1 walk-in coolers. These practices had the potential to affect food served to residents. Findings included: 1. An observation and interview on the 600 hall nourishment room refrigerator conducted with Nurse Aide (NA) #4 and NA #5 on [DATE] at 10:45 AM revealed a bag of croutons not labeled or dated, a quart size sealed plastic bag with strawberries and blueberries that were observed to have discoloration and with fuzzy white substance, a microwavable dinner tray not labeled or dated of meat and… […]