Autumn Care of Shallotte

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jan 5, 2024

  Based on record review, observations, and staff and resident interviews, the facility failed to ensure a resident was safely transferred into the facility's transportation van, when the Transport Driver failed to utilize the safety strap while the lift platform was being raised on the facility van. This resulted in the resident (Resident #3) falling from the lift and sustaining injuries to the left side of his head, left wrist, and left elbow. This occurred when the facility Transport Driver was picking up Resident #3 from a doctor's office appointment on 11/29/2023. […]

• Actual harm, isolatedF600Jul 27, 2023

  Based on observations, record review, staff, Psychiatrist, Nurse Practitioner interviews and the Medical Directors interview the facility failed to protect a residents right to be free from abuse when a cognitively impaired resident (Resident # 46) had physical and verbal altercations against another cognitively impaired resident (Resident #53). During an initial altercation Resident #46 was observed grabbing Resident #53's arms and pulling them away from his face and yelling at him, there were no injuries reported. During a second altercation Resident #46 became agitated and attempted to lash out at Resident #53, there were no injuries reported. […]

• No harm, potential for more than minimal, widespreadF908Mar 3, 2022

  Based on observation, staff interview and review of the manufacturer's instructions, the facility failed to clean the laundry dryer lint filter according to the manufacturer's specifications for 2 of 3 dryers. The findings included: Review of the User's Guide for Dryers dated May 2020 from Alliance Laundry Systems read: ALWAYS clean the lint filter after every load. On 3/3/22 at 12:00 PM an observation of the laundry with the Laundry Employee #1 that was working in the laundry. Two of 3 dryers contained linens or clothing and were operational. Laundry Employee #1 stated she worked 7:30 AM to 3:30 PM and another employee worked from 2 PM to 10 PM and the laundry was staffed 7 days a week. […]

• No harm, potential for more than minimal, patternF756Jul 25, 2025

  Based on record review and staff, Nurse Practitioner and Consultant Pharmacist interviews, the pharmacy failed to notify the facility of a clinical high priority recommendation that required a prompt response. This failure contributed to the facility not administering the antibiotics cefdinir and doxycycline prescribed to a resident (Resident # 4) for sepsis due to pneumonia from 7/17/25 through 7/20/25. This occurred for 1 of 5 residents reviewed for medication administration. Findings included:Resident # 4 was admitted on [DATE] with diagnosis of chronic respiratory failure with hypoxia, congestive heart failure, and chronic obstructive pulmonary disease. […]

• No harm, potential for more than minimal, patternF760Jul 25, 2025

  Based on record review and staff, Nurse Practitioner and Consultant Pharmacist interviews, the facility failed to: a). administer the antibiotic medications doxycycline and cefdinir per the physician orders on the discharge summary from 7/18/25 through 7/20/25 resulting in 12 missed doses of the antibiotic treatment for pneumonia and b). failed to administer the ordered dose of roflumilast (a medication used to treat severe Chronic Obstructive Pulmonary Disease) for 2 consecutive days. There was no significant outcome due to either of the medication errors. This deficient practice occurred for 1 of 1 resident (Resident #4) reviewed for significant medication errors. […]