Autumn Hills Care Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jan 28, 2025

  Based on observation, interview, record review, review of photographs provided by Resident #27's fiancee/power of attorney (POA) and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers and timely identify new pressure ulcers, including timely incontinence care and turning and repositioning. This affected two residents (#27 and #109) of two residents reviewed for pressure ulcers. The facility census was 106. […]

• Actual harm, isolatedF686Feb 2, 2021

  Based on interview, observation, record review and policy review, the facility failed to ensure appropriate interventions were implemented to prevent the development of a pressure ulcer for Resident #69. Actual Harm occurred on 12/23/20 when Resident #69 who required two person assist with bed mobility and was totally dependent with two person assist with transfers was found to have his over the bed table wedged against his right knee resulting in an unstageable pressure ulcer (full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar) when first observed by Registered Nurse (RN)/Wound Nurse #611. This affected one resident (Resident #69) of three residents reviewed for pressure ulcers. The facility census was 100. […]

• No harm, potential for more than minimal, widespreadF725Aug 26, 2026

  Based on review of the facility's staffing schedules, resident and staff interviews, record review, and policy review, the facility failed to ensure sufficient staffing was provided to meet residents' care needs. This affected eight (Residents #80, #3, #7, #64, #77, #4, #31, and #15) and had the potential to affect all 104 residents residing in the facility.Findings include:1. An interview with Resident #80 on 08/17/26 at 11:48 A.M. revealed he hadn't been shaved or showered in over a week because there wasn't enough staff on the floor.Record review showed Resident #80 required extensive assistance with all activities of daily living (ADL). Interview on 08/17/26 revealed he had not been shaved in a week and had not received a shower since 08/11/26, despite being scheduled twice weekly. […]

• No harm, potential for more than minimal, widespreadF727Aug 26, 2026

  Based on review of the facility's staffing schedules, staff interviews, and policy review, the facility failed to ensure eight consecutive hours of registered nurse (RN) coverage each day as required. This had the potential to affect all 104 residents residing in the facility.Findings include:Review of the facility staffing schedule and completion of the staffing tool for 07/03/26 through 07/06/26 revealed the facility did not have eight consecutive hours of RN coverage in the facility on 07/04/26.An additional review of the staffing schedule and completion of the staffing tool revealed the facility did not have eight consecutive hours of RN coverage on 07/11/26.During an interview on 08/17/26 at 4:00 P.M., the Corporate Human Resources Director and Recruiter #641 and the Facility… […]

• No harm, potential for more than minimal, widespreadF761Aug 26, 2026

  Based on observation, interview, review of manufacturers guidelines, and policy review, the facility failed to store medications in a manner that preserved their efficacy and proper discard time frames. This had the potential to affect all residents in the facility. The facility census was 104.Findings include:On 08/19/26 at 4:15 P.M., an observation of the medication storage room on the 300 unit revealed a one milliliter vial of Tubersol (a serum used for Tuberculosis testing). The vial was open and not labeled with the date it was opened. […]