Autumnwood Care Center

In the surveyor’s words

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

• Actual harm, isolatedF760Apr 22, 2026

  Based on medical record review, resident interview, observation, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors and further failed to ensure medications were administered as ordered. This resulted in Actual physical harm and emotional distress for one (#10) resident on 04/19/26 at 10:17 A.M. when Resident #10 verbalized being distraught about not receiving her anti-anxiety medication (Ativan) because the facility had run out and she had not received the evening dose (to be administered between 3:00 P.M. and 6:00 P.M.) on 04/18/26 and the early dose (to be administered between 5:00 A.M. and 10:00 A.M.) on 04/19/26, and she was observed to be shaking, tearful and in emotional distress requiring staff intervention. […]

• Actual harm, isolatedF760Jan 21, 2025

  Based on medical record review, staff interview, and facility policy review, the facility failed to ensure a medication order was complete and accurate and further failed to ensure the medication order was transcribed correctly to make certain Resident #10 was administered the correct medication. Actual Harm occurred when an incomplete verbal order for a critically low potassium level (2.7 milliequivalents per liter [mEq/L] with normal potassium blood serum measuring between 3.5 and 5.5 mEq/L) was transcribed and medication administered inaccurately, resulting in Resident #10 receiving a medication to remove potassium from the blood rather than a medication to replace potassium (low potassium could result in cardiac arrhythmia, numbness, tingling, muscle weakness, spasms, and or muscle… […]

• Actual harm, isolatedF684Oct 4, 2022

  Based on medical record review, staff interview, physician interview, review of the hospital records, and policy review, the facility failed to ensure early identification of a change in the resident's condition. This resulted in Actual Harm when Resident #41, who was taking an anticoagulant medication, experienced a moderate amount of blood in the stool during a bowel movement. A thorough assessment and immediate notification to the physician was not completed. Subsequently, approximately 33 hours later the resident was hospitalized and received three units of packed red blood cells for a critical low hemoglobin level. This affected one (Resident #41) of one resident reviewed for anticoagulant therapy. […]

• No harm, potential for more than minimal, widespreadF577Apr 22, 2026

  Based on observation, resident interview, and staff interview, the facility failed to ensure state survey results were available without having to request them. Furthermore, the facility failed to ensure notice of the availability of the state survey results were posted in prominent and accessible areas for the residents/public. This had the potential to affect all residents. The facility census was 88.Findings include:Interview on 04/21/26 at 8:38 A.M. with Resident's #15, #19, #25, and #70 revealed they were not aware where the state survey results could be found.Observation on 04/21/26 at 9:45 A.M. […]

• No harm, potential for more than minimal, widespreadF641Apr 22, 2026

  Based on observation, record review, staff interview, review of the Resident Assessment Instrument (RAI), review of the National Institute of Health website, and facility policy review the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded. This affected three residents (#12, #52, and #76) and had the potential to affect six residents (#12, #14, #30, #47, #52, #76) the facility identified as being invasive ventilator dependent. The facility census was 88.Findings include:1. Review of Resident #12's medical record revealed an admission date of 10/16/12. […]