Autumn Care of Salisbury

Inspectors wroteBased on observations and staff interviews, the facility failed to store, label and date food in 1 of 1 freezer reviewed for safe food handling. During an observation conducted with the Dietary Manager, multiple food items were observed removed from their original packaging, placed in resealable plastic bags without labeling, and lacked open and/or expiration dates. Additionally, food items in original packaging were observed without opening or expiration dates. These findings had the potential to affect the safety and quality of food served to residents.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to secure cords from wall-mounted televisions which could cause a tripping hazard for 7 of 27 rooms (603,604, 605, 606, 607, 608, and 609) on 1 of 4 halls (600 hall).

Inspectors wroteBased on record review and interviews with the Power of Attorney (POA), staff, and the Nurse Practitioner (NP), the facility failed to ensure a resident's advance directive information was accurate and consistent throughout the medical record for 1 of 3 residents reviewed for advance directives (Resident #3). Resident #3 was admitted to the facility on [DATE]. Resident #3's electronic health record (EHR) revealed the resident's code status was listed as full code in the EHR banner. Resident #3's care plan dated 1/9/2026 revealed Resident #3 was a full code. A discharge return anticipated [NAME] Data Set (MDS) dated [DATE] indicated Resident #3 was discharged to the hospital. An entry MDS dated [DATE] indicated Resident #3 was readmitted to the facility. [...]

Inspectors wroteBased on record review and staff, resident, and Urologist interviews, the facility failed to ensure a follow-up urology appointment was scheduled and completed as ordered for 1 of 3 residents reviewed for urinary catheter (Resident #39). Resident #39 was admitted to the facility on [DATE]. Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. A review of the hospital urology consult after-visit summary dated 01/13/2026 revealed Resident #39's suprapubic catheter was changed, with instructions to follow up on 02/10/2026 for routine catheter replacement. A review of Nurse #1's progress note dated 01/13/2026 revealed the suprapubic catheter was changed, and Resident #39 was to return for a urology follow up appointment on 02/10/2026. A phone interview was attempted with Nurse #1 on 03/30/2026 at 2:00 PM; [...]

Inspectors wroteBased on observations, record review, manufacturer's instructions, and interviews with staff, Medical Director, and the Nurse Practitioner, the facility failed to dispose of single use feeding tube declogging devices contrary to manufacturer instructions, which increased the risk of contamination and infection (Resident #5) and failed to ensure a resident was administered the tube feeding formula specified in the physician order (Resident #37) for 2 of 2 residents reviewed for tube feeding (Resident #5 and Resident #37).

Inspectors wroteBased on record review, Resident Representative, Nurse Practitioner, and staff interviews, the facility failed to implement their abuse policy and procedures in the areas of reporting, investigation and protection after an allegation of abuse for 1 of 4 residents reviewed for abuse (Resident #1).

Inspectors wroteBased on observation and staff interviews, the facility failed to label and date leftover food items, remove food items with signs of spoilage and not store staff food in 1 of 2 nourishment room refrigerators (the 600 Hall nourishment room); and failed to remove expired food stored for use in 1 of 1 walk-in coolers. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record reviews, and residents and staff interviews, the facility failed to honor residents' preferences for a shower for 3 of 3 residents reviewed for choices (Resident #32, Resident #77, and Resident# 24.)

Inspectors wroteBased on record review, and Responsible Party and staff interviews, the facility failed to make prompt efforts to resolve a grievance 1 of 3 residents reviewed for grievances (Resident #72).

Inspectors wroteBased on record review and staff interviews the facility failed to protect a resident's right to be free from staff to resident abuse. While Nurse Aide (NA) #6 and NA #7 were providing care for a cognitively impaired resident, the resident became agitated. NA #7 slapped the resident on the left upper thigh and NA #6 held the residents' hands during care while the resident was agitated and being combative. This deficient practice was found for 1 of 3 residents reviewed for abuse (Resident #3).

Inspectors wroteBased on record review and staff interviews, the facility failed to follow and implement abuse policies in the area of identification, protection and reporting for 1 of 3 residents reviewed for abuse (Resident #3). While Resident # 3 was being abused, Nurse Aide (NA) #6 did not intervene, stop, or report NA #7 when she slapped Resident #3 on the thigh. Also, NA #7 did not intervene or report immediately NA #6 for restraining Resident #3's hands during care when NA #6 held onto Resident #3's hands with her hands. As a result, NA #6 and NA #7 worked the rest of their shift, putting other residents at risk for abuse.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to store an enteral feeding syringe with the plunger separated from the syringe for 2 of 4 residents (Resident #44 and Resident #65) reviewed for enteral feeding management. This practice had the potential for bacterial growth and contamination.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to provide clean air intake filters on oxygen concentrators for 2 of 4 residents (Resident #34 and Resident #44) reviewed for respiratory care.

Inspectors wroteBased on record review, and family member, Physician, and staff interviews, the facility failed to ensure a resident was transported to a scheduled neurologist appointment on 2/28/25 for 1 of 1 resident reviewed for medical related social services (Resident #72).

Inspectors wroteBased on record review and staff, Physician's Assistant interviews, the facility failed to ensure 1 of 4 residents (Resident #72) reviewed for medication administration was provided medication from the pharmacy as ordered by the physician.

Inspectors wroteBased on record review, and staff, Physician's Assistant and Physician interviews, the facility failed to ensure 1 of 4 residents (Resident #72) reviewed for medication administration was free of significant medication errors. Resident #72 was not administered six doses of Carbidopa-Levodopa (a drug that treats Parkinson's disease, a central nervous system disease) 25-100 milligrams 2 ½ tablets which was ordered four times a day.

Inspectors wroteBased on record reviews, observations, resident and staff interviews, the facility failed to determine whether the self-administration of medications was clinically appropriate for 2 of 2 sampled residents (Resident # 55 and Resident # 37) who were observed to have a medication at bedside.

Inspectors wroteBased on staff interviews and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 calendar days for 1 of 1 resident (Resident #37) reviewed who was identified by the facility as having a significant change in condition.

Inspectors wroteBased on staff interview, and record review the facility failed to review and revise comprehensive care plans for 2 of 2 residents reviewed for comprehensive care plan review and revision. The resident's care plan must be reviewed after each Minimum Data Set (MDS) assessment time frame and revised based on changing goals, preferences and needs of the resident and in response to current interventions for the resident to meet resident care needs (Residents # 62 and # 75).

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to keep a urinary catheter bag and/or the catheter tubing from touching the floor to reduce the risk of infection or injury for 1 of 2 residents (Resident #85) reviewed with indwelling urinary catheters.