Autumn Care of Saluda

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of pressure ulcers for 1 of 2 residents reviewed for pressure ulcers (Resident #2).Findings included:Resident #2 was admitted to the facility on [DATE].Review of Resident #2's admission skin assessment dated [DATE] identified a pressure ulcer located on sacrum (the bone at the base of spine and top inner area of the buttock). The stage of the pressure ulcer was not included in the assessment. Review of a nurse's progress note dated 01/07/26 revealed Resident #2 had a reddened area on the bilateral inner/top area of the buttock that was covered with foam dressing.Review of Resident #2's Medication Administration Record (MAR) revealed a physician's order was transcribed with directions to cleanse the bilateral inner area on the buttock with normal saline and apply a foam border dressing. The treatment was initialed by the nurse to indicate it was done on 01/08/26.Review of a nurse's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and staff interviews, the facility failed to complete quarterly smoking risk assessments (assessment of a resident to determine if they are safe to smoke where a score between 0-9 indicates a resident was a safe smoker) for 1 of 2 residents reviewed for smoking (Resident #54).The findings included:Resident #54 was admitted to the facility on [DATE] with diagnoses which included mood disorder, nicotine dependence, and muscle weakness. Review of the facility's smoking policy dated 09/09/25 revealed a smoking risk assessment must be completed upon admission, quarterly, and upon changes in the resident's condition.Review of Resident #54's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and coded for tobacco use.Review of Resident #54's quarterly MDS dated [DATE] revealed the resident was cognitively intact and independent for most activities of daily living (ADL). The MDS indicated Resident #54 was independent for ambulation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff and Nurse Practitioner (NP) interviews, the facility failed to effectively supervise a cognitively impaired resident when the resident was able to exit the facility unsupervised and without staff knowledge for 1 of 3 residents reviewed for supervisions to prevent accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis that included dementia, bipolar disorder, panic disorder, and anxiety disorder.Review of the annual minimum data set (MDS) dated [DATE] revealed that Resident #1 was severely cognitively impaired. He displayed no wandering behavior during the look back period and needed supervision with mobility and transfers. Resident #1 had no falls and needed supervision with ambulation. Review of the care plan started on 12/9/24 and last updated on 12/16/25 revealed that Resident #1 waws at risk of elopement- wandering in facility I'm gonna walk out the door - may stand by exit doors, may try to follow behind…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews with residents and staff, the facility failed to protect the resident's right to be free from misappropriation of controlled narcotic pain medications for 3 of 4 residents reviewed for misappropriation of property (Resident #46, #1, and #18). Findings included: The facility's Abuse, Neglect, and Exploitation policy, last revised 7/11/24 revealed the facility would not tolerate misappropriation of resident property defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings without consent. a. Resident #46 was admitted to the facility on [DATE]. Resident #46's diagnoses included osteoarthritis and right hip pain. A physician's order dated 4/9/24 revealed Resident #46 received hydrocodone-acetaminophen (a combination of a narcotic opioid analgesic and a non-narcotic medication used to relieve pain) 5-325 milligram (mg) tablet before meals and at bedtime for right hip pain. The significant change in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to discard potentially hazardous food with signs of spoilage in 1 of 1 walk-in refrigerators, date food items available for residents in 1 of 1 kitchen refrigerators and discard damaged canned goods available for use. This practice had the potential to affect food served to residents. Findings included: a. An observation of the walk-in refrigerator on 02/26/24 at 08:56 AM revealed the following: - A box containing cucumbers with a received date of 12/31/24 that was shriveled with white on the surface. - A box of green bell peppers with a received date of 1/14/25 that was shriveled with black on the surface. b. An observation of the kitchen refrigerator on 02/26/24 at 08:56 AM revealed the following: - 1 ham and cheese sandwich and 1 peanut butter and jelly sandwich that were not dated. c. An observation of the canned goods rack on 02/11/25 at 10:00 AM revealed the following: - An unopened can of catsup with a dent approximately 3 inches wide across the front of it available for use. An interview on 02/11/25 at 10:01 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, Nurse Practitioner (NP), Director of Nursing (DON) and Administrator, the facility failed to protect the resident's right (Resident #1) to be free of abuse when Resident #2's family member (facility Housekeeper) pulled Resident #2's TV remote from Resident #1's hands. Resident #1 sustained a fracture of his left index finger that required no surgical intervention. This deficient practice occurred for 1 of 1 resident reviewed for abuse. Findings Included: Resident #1 was admitted to the facility on [DATE] with diagnoses including stroke, paralysis of the right side and legal blindness. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #1 as severely cognitively impaired with no behaviors noted. Resident #1 was care planned (2/7/23) for altered or at risk for altered behaviors and/ or mood with a history of yelling, cursing, paranoid, history of cycling through roommates, history of many room changes due to anger, and behavior. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a lunch meal tray line observation, record review, and staff interviews the facility failed to serve correct portions of food according to the planned menus. This failure had the potential to affect 61 residents receiving a regular diet texture and 6 residents receiving a pureed diet texture. Findings included: 1. The menu for the lunch meal on 10/31/23 for residents receiving a regular texture diet was 2 ounces of baked chicken, a half-cup of au-gratin potatoes, and a half-cup of mixed vegetables. A continuous observation of the lunch meal tray line on 10/31/23 from 12:00 PM through 12:55 PM revealed [NAME] #2 began plating food and used tongs to place a mixture of bone-in and boneless chicken thighs for residents receiving a regular diet texture. There was no consistent size to the pieces of chicken thighs being served. In an interview with the Dietary Manager on 10/31/23 at 12:05 PM she confirmed the chicken being served at the lunch meal was a mixture of boneless and bone-in chicken thighs. When the surveyor asked her how she could verify residents were receiving the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews the facility failed to maintain a clean floor and walls and label and date food and beverage items in 1 of 1 walk-in cooler; maintain a clean floor, cover food, and store food items off the floor for 1 of 1 walk-in freezer; date food items, store food off the floor, and remove expired food in 1 of 1 dry goods storage room; maintain clean stove, oven, shelves, and floor in 1 of 1 kitchen; cover, label, and date open beverage and food items, discard food with signs of spoilage, and maintain a clean reach-in cooler for 1 of 1 reach-in cooler; cover, label, and date food items and maintain a clean reach-in freezer for 1 of 1 reach-in freezer; restrain facial hair during food preparation; maintain 1 of 1 garbage disposal in working order; and ensure food items were labeled and dated in 1 of 2 nourishment rooms (A/B hall). Findings included: 1. An initial tour of the walk-in cooler on 10/29/23 at 10:27 AM revealed the following: (a). multiple dried brown stains were observed on the floor and multiple areas of a black/brown substance to all walls…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 05/12/22. This was for one repeat deficiency originally cited in the area of food procurement-store/prepare/serve that was subsequently recited on the current recertification and complaint investigation survey of 11/01/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referenced to: F 812: Based on observations and staff interviews the facility failed to maintain a clean floor and walls and label and date food and beverage items in 1 of 1 walk-in cooler; maintain a clean floor, cover food, and store food items off the floor for 1 of 1 walk-in freezer; date food items, store food off the floor, and remove…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated dietary and staffing concerns voiced by residents during Resident Council meetings for 7 of 9 months reviewed (February 2023, April 2023, May 2023, June 2023, July 2023, September 2023, and October 2023). Findings included: The Resident Council minutes for the period January 2023 through October 2023 were reviewed and revealed the following: • Resident Council minutes dated 02/22/23 noted in part, residents voiced staffing concerns that third shift agency staff talked loudly in the halls, did not answer call lights, and wore ear buds to talk on their cellphones. In addition, food on the meal trays were served cold and ice cream was not kept cold. • Resident Council minutes dated 03/29/23 noted the staffing and dietary concerns voiced during the previous month's meeting were reviewed and reported as resolved. There were no new staffing or dietary concerns noted as voiced during the meeting. • Resident Council minutes dated 04/26/23 noted in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 of 4 sampled residents observed with medications at bedside (Resident #64). Findings included: Resident #64 was admitted to the facility on [DATE]. His diagnoses included congestive heart failure, diabetes, and left shoulder pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had intact cognition. Review of the medical record revealed no documentation that Resident #64 was assessed for self-administration of medications. During an observation and interview on 10/31/23 at 1:05 PM, Resident #64 was sitting up on the side of his bed with the overbed table pulled directly in front of him and placed on top of the overbed table was his lunch tray and a medicine cup containing 2 round white pills. Resident #64 explained earlier that morning he had 3 teeth pulled and the pills in the medicine cup were the Tylenol he requested for pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASRR) and wandering behavior for 3 of 22 sampled residents reviewed (Residents #10, #26 and #83). Findings included: 1. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety disorder and depression. a. Review of an undated North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document revealed Resident #10 had a time-limited Level II PASRR with an effective date of 09/02/22 and expiration date of 10/02/22. The admission MDS assessment dated [DATE] indicated Resident #10 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. b. Review of an undated NC MUST inquiry document revealed Resident #10 was re-evaluated on 02/06/23 by PASRR due to a change of condition and issued a new…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #9 was admitted to the facility 02/11/20 with diagnoses including heart failure and quadriplegia (paralysis that affects all four limbs). The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Review of Resident #9's physician orders revealed no current order for the use of zinc oxide cream. During observations on 10/29/23 at 12:42 PM, 10/20/23 at 8:27 AM, 10/31/23 at 8:46 AM, and 11/01/23 at 8:14 AM, in clear view on top of a shelf in Resident #9's room was a 15-ounce container of medicated cream with the active ingredient 25% zinc oxide. An interview with Resident #9 on 10/29/23 at 12:43 PM revealed the zinc cream was applied by staff but had not been applied for a while. An observation and interview were conducted on 11/01/23 at 4:22 PM with the Director of Nursing (DON). The DON observed the medicated cream on the shelf and explained it could not be kept in Resident #9's room. She stated a physician order would need to be in place for the use of zinc oxide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.