Autumn Court

In the surveyor’s words

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

• Immediate jeopardy, isolatedF805Jun 25, 2026

  THIS DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PIOR TO THIS SURVEY. Based on closed medical record review, staff interview, paramedic interview, review of the Emergency Medical Services (EMS) run report, review of the hospital records and review of the facility policies, the facility failed to ensure residents were served foods in the physician ordered diet texture to meet individual needs. This resulted in Immediate Jeopardy and serious life-threatening harm, negative health outcomes and/or death on 05/02/26 for one (#09) resident when Resident #09, who had a chopped meat diet order, was able to consume a piece of chicken that was not prepared per their physician prescribed diet order. […]

• No harm, potential for more than minimal, widespreadF800Aug 6, 2026

  Based on medical record review, staff interview and policy review, the facility failed to ensure residents were provided with a nourishing and well-balanced nutritional diet that met their nutritional needs when the stove was unavailable for food preparation and thereafter. This affected all residents reviewed for nourishing and well-balanced meals. The facility identified that all residents received food from the kitchen The facility census was 48. Findings include:Interview on 08/03/26 at 8:18 A.M. with Dietary Manager (DM) #214 revealed a new stove has been in place for approximately two weeks. DM #214 continued to state the facility was without a working stove for approximately a month. Interview on 08/03/26 at 9:14 A.M. […]

• No harm, potential for more than minimal, widespreadF921Aug 6, 2026

  Based on observation, resident interview, staff interview, and policy review the facility failed to ensure the environment was free from pervasive odors. This had the potential to affect all residents who reside in the facility. The facility census was 48.Findings include:Observation on 08/03/26 at 8:41 A.M. revealed upon entering the facility the building had a strong urine odor that was musty and filled the entire facility.Interview on 08/03/26 at approximately 9:00 A.M. with Social Services (SS #202) verified the strong urine smell throughout the facility. SS #202 stated it is in the carpet that is in the hallways that has been in place for a long time. SS #202 stated they have tried to have the carpets cleaned but the smell remained.Observation on 08/03/36 at 9:40 A.M. […]

• No harm, potential for more than minimal, widespreadF812Oct 17, 2024

  Based on observation, staff interview, and review of the dishwasher manufacturer's guidelines, the facility failed to ensure the dishwasher washed and rinsed dishes at temperatures specified by the manufacturer's guidelines. This had the potential to affect all 48 residents who received food from the kitchen. The facility census was 48. Findings include: Observation on 10/16/24 at approximately 11:00 A.M. revealed the dishwasher labeled with Machine Operational Requirements with a wash temperature of 120 degrees Fahrenheit (F) minimum and a rinse temperature of 120 degrees F minimum. Further observation revealed Dietary Director (DD) #114 running one cycle of the dishwasher and the was temperature reached 80 degrees F during the wash and a rinse temperature of 88 degrees F. […]

• No harm, potential for more than minimal, widespreadF812Jul 7, 2022

  Based on observations, resident and staff interview, review of the facility infection control log and review of the owner's manual for the chemical dishwasher, the facility failed to ensure dietary staff with skin conditions kept their arms properly covered and failed to ensure the chemical dishwashing machine maintained the appropriate level of chemicals for effective sanitation. This had the potential to affect all 49 residents residing in the facility. The facility census was 49. Findings include: 1. Observation on 07/05/22 at 8:51 A.M. of the kitchen found Dietary Staff (DS) #412 wearing a short sleeve black shirt. DS #412's arms were exposed and observed having flakey, white, scale like skin on both his right and left forearms. […]