Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Care Of Biscoe during CMS and state inspections, most recent first.
Staff failed to promptly report suspected theft of money and personal items belonging to three residents to the Administrator and Adult Protective Services, as required by facility policy. In each case, residents reported missing property to staff, but notifications to the Administrator and external authorities were delayed or not made, and required investigation reports were not submitted within the mandated timeframe.
Two residents did not have their MDS assessments accurately coded: one received insulin injections that were not documented in the MDS, and another had significant dental issues that were not reflected in the assessment. The MDS nurse acknowledged these oversights, and the DON confirmed the expectation for accurate assessments.
A resident with multiple health conditions and severe cognitive impairment had an order for a divided plate to assist with meals, but the use of this adaptive equipment was not included in the resident's nutrition care plan. Staff confirmed the omission, despite the resident being observed using the divided plate during meals.
A facility failed to act on a hospital discharge order for a nephrology follow-up appointment for a resident, resulting in the resident requiring antibiotics to treat multiple UTIs over several months. The resident's electronic medical record did not include any documentation of nephrology or urology consultations, and interviews confirmed that the nephrology appointment order was never executed.
The facility failed to maintain a clean, home-like environment in the main dining room, with a dirty, sticky floor and a dirty window observed over three days. Additionally, the facility did not effectively repair a leaking roof, affecting multiple areas, including resident rooms and common areas, despite obtaining vendor estimates and submitting repair requests.
A resident with bipolar disorder was administered the incorrect dosage of Depakote (valproic acid) 250 mg DR tablets instead of the prescribed 125 mg DR tablets. The error was discovered during a medication pass observation, and subsequent interviews revealed that staff failed to verify the medication dosage against the MAR. The Pharmacy Manager confirmed the correct order was on file, but the facility had not reported the error.
The facility failed to label, date, and discard expired food items, enforce proper hair restraint during meal preparation, maintain milk at the required temperature, and repair a peeling kitchen ceiling. These lapses were observed during a survey and acknowledged by the Dietary Manager, Corporate Dietary Consultant, and Maintenance Manager, with the Administrator being unaware of these issues.
The facility's QAPI committee failed to maintain effective procedures and monitor interventions, resulting in repeated deficiencies. Issues included an unclean dining room, failure to follow up on medical orders, unsecured medications, and inadequate nail care for dependent residents. The Administrator cited staff turnover during the pandemic as a contributing factor.
The facility failed to provide dietary supplements as ordered for two residents, leading to deficiencies in their nutritional care. One resident did not receive a high-calorie Magic Cup and soft sandwich, while another did not receive fortified pudding, contributing to their continued weight loss and inadequate oral intake. The deficiencies were due to lapses in communication and oversight in the dietary department.
A nurse left medications at the bedside of a cognitively impaired resident without an order for self-administration, and multi-use medications in two medication carts were not dated upon opening. The DON and nursing staff acknowledged lapses in compliance with protocols for securing and dating medications.
Failure to Timely Report and Investigate Suspected Theft of Resident Property
Penalty
Summary
The facility failed to report suspected misappropriation of resident property, including theft of money and personal items, to the Administrator/Abuse Coordinator and Adult Protective Services for three residents. According to the facility's Abuse, Neglect and Exploitation policy, all allegations or suspicions of abuse, neglect, exploitation, or misappropriation of resident property must be immediately reported to the Administrator/Abuse Coordinator, who is then responsible for notifying local and state agencies and completing an investigation within five working days. In these cases, staff members notified their immediate supervisors or the Director of Nursing (DON) about the missing property, but the required notifications to the Administrator and Adult Protective Services were either delayed or not made at all. For one resident, a lock box containing money and a personal ring was reported missing. The resident and a nurse aide both confirmed the loss, and the unit manager was notified, who in turn informed the DON. However, the Administrator was not notified until two days later, and Adult Protective Services was not contacted. Additionally, the required 5-day investigation report was not submitted to the state survey agency within the specified timeframe. Similar failures occurred with two other residents: one reported a missing wallet with cash, and another reported a missing lock box with a significant amount of money. In both cases, staff followed internal grievance procedures but did not ensure timely notification to the Administrator or Adult Protective Services, and the 5-day investigation reports were either delayed or not completed as required. The residents involved were cognitively intact or able to express their needs, and each reported the loss of personal property directly to staff. Despite these reports, the facility did not adhere to its own policy for reporting and investigating suspected misappropriation. The lack of timely and appropriate notification to both internal and external authorities constituted a failure to protect residents' property and to comply with regulatory requirements for reporting and investigation.
Inaccurate MDS Coding for Medications and Dental Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of medication administration and dental status. For one resident with diabetes, physician orders and medication administration records showed that insulin injections were administered on seven days during the lookback period. However, the quarterly MDS assessment incorrectly indicated that no injections or insulin were given during this time. The MDS nurse acknowledged this was an oversight during an interview. For another resident with multiple diagnoses, including diabetes and heart failure, the significant change MDS assessment documented no oral or dental problems. Direct observation and an oral assessment revealed the resident had multiple missing, broken, and decayed teeth. The MDS nurse confirmed that the resident's dental status was not accurately reflected on the assessment and should have been coded as having obvious or likely cavities. The DON stated that assessments are required to accurately reflect a resident's dental status.
Failure to Include Adaptive Equipment in Nutrition Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan addressing all of a resident's nutritional needs. Specifically, a resident with a history of cerebrovascular accident (CVA), cognitive communication deficit, dysphagia, congestive heart failure, diabetes mellitus, impaired mobility, and weight loss had an active physician order for adaptive equipment—a divided plate—to assist with meals. Despite this order and the resident's severe cognitive impairment, the care plan reviewed did not include the use of a divided plate as an intervention under the nutrition focus area. Observations confirmed that the resident was consistently provided with a divided plate during meals, yet this intervention was not documented in the care plan. Staff interviews, including those with the MDS nurse and the registered dietitian, verified that the divided plate should have been included in the care plan but was omitted. The administrator also acknowledged that the care plan should have reflected the use of the divided plate during meals.
Failure to Schedule Nephrology Follow-Up Leads to Multiple UTIs
Penalty
Summary
The facility failed to act on a hospital discharge order for a nephrology follow-up appointment for a resident, resulting in the resident requiring antibiotics to treat multiple urinary tract infections (UTIs) over a period of several months. The resident, who was admitted with diagnoses of congestive heart failure and chronic kidney disease, had a hospital discharge summary that included an order for a nephrology consult within 2-4 weeks. However, the facility did not schedule or complete this consultation, and the resident was treated for UTIs on five separate occasions. The resident's electronic medical record did not include any documentation of nephrology or urology consultations from the time of admission to the time of the surveyor's review. Interviews with the resident, the physician, and the administrator confirmed that the nephrology appointment order from the hospital discharge paperwork was never executed. The resident, who was cognitively intact and dependent on staff for toileting, experienced dysuria and was recently treated with antibiotics for a UTI. The physician expected that any orders for consultations would be scheduled and completed as ordered. The administrator acknowledged that the nephrology appointment order was missed and that new orders for a urology consultation were obtained only after the surveyor's review. Attempts to contact the nurse responsible for entering the admission orders were unsuccessful.
Failure to Maintain Clean Environment and Repair Leaking Roof
Penalty
Summary
The facility failed to provide a clean, home-like environment in the main dining room, as evidenced by a dirty, sticky floor and a dirty window. Observations over three consecutive days revealed that the floor in the entryway with vending machines and food serving cabinets had a moderate amount of brown soil sticking to shoes, and the window had a large amount of spider webs with black soil affecting visibility. The lead Housekeeper admitted that housekeeping was responsible for cleaning the floor and dusting the main dining room daily but was unaware that the floor had not been mopped since before Monday and was sticky. She stated she would mop the floor and clean the dirty window immediately. However, the conditions remained unchanged during the observations on the subsequent days. The facility also failed to repair a leaking roof, which affected multiple areas, including resident rooms, the nurses' station, the nutrition room, the medication room, the living room, the soiled utility room, the Director of Nursing's office, the Unit Manager's room, the conference room, the laundry room vents, and the front dining room. Despite obtaining a vendor estimate and submitting a capital purchase request for roof repair or replacement, the facility only approved patch repairs, which were ineffective as new leaks continued to appear. Interviews with the Maintenance Manager and the Administrator confirmed that the roof had been leaking for months, and patching was not a viable solution. Residents reported ongoing leaks in their rooms, with water on the floor and ceiling damage, indicating that the roof needed to be replaced rather than patched.
Significant Medication Error Due to Incorrect Dosage Administration
Penalty
Summary
The facility failed to prevent a significant medication error for a resident diagnosed with bipolar disorder, anxiety, and depression. The resident was prescribed Depakote (valproic acid) 125 mg Delayed Release (DR) tablets to be administered twice a day. However, the Medication Administration Record (MAR) for March 2024 revealed that Depakote 250 mg DR tablets were administered instead. This error was discovered during a medication pass observation on 03/05/24, where it was noted that the medication cart contained only Depakote 250 mg DR tablets, and not the prescribed 125 mg DR tablets. Nurse #1 confirmed the error and retrieved the correct dose from the facility's backup system for administration. A subsequent valproic acid level test for the resident showed a sub-therapeutic level of 22.4 mcg/ml, well below the reference range of 50.0-100.0 mcg/ml. Interviews with various staff members, including Nurse #1, Nurse #7, and Nurse #10, revealed that the incorrect dosage had been administered due to a failure to verify the medication dosage against the MAR. Nurse #7 admitted to administering the 250 mg tablets that were available in the medication cart without checking the dosage. Similarly, Nurse #10 acknowledged the possibility of not verifying the dosage amount during her shifts. The Director of Nursing (DON) and the Medical Director both emphasized that medications should be administered per the prescribed orders and that the rights of medication administration should be followed. The Pharmacy Manager confirmed that the pharmacy had the correct order for Depakote 125 mg DR tablets but did not know why the 250 mg tablets were sent to the facility. The facility had not reported the error to the pharmacy, which would have triggered an investigation. The DON and the Administrator reiterated the importance of following the correct procedures for medication administration, including verifying the correct dosage. The error was not identified until it was brought to the attention of the DON, highlighting a lapse in the facility's medication administration process.
Multiple Deficiencies in Food Safety and Kitchen Maintenance
Penalty
Summary
The facility failed to properly label, date, and discard expired food items in the walk-in refrigerator. During an observation, various food items such as turkey sandwich meat, cooked ham, shredded cheese, sliced cheese, and chocolate pudding were found either expired or not dated. The Dietary Manager acknowledged that the Cook was responsible for discarding expired food and labeling food items, but this was not done. The Administrator was also unaware of the issue, indicating a lapse in oversight and responsibility for food safety protocols. The facility also failed to enforce proper hair restraint during meal preparation and food plating. The Dietary Manager and a Dietary Aide were observed with hair nets that did not cover all their hair, allowing braids and curls to swing freely. Both staff members were unaware that all hair needed to be covered by a hair net, despite the facility's in-service documentation on physical contamination prevention. The Administrator was not aware of this non-compliance, highlighting a gap in staff training and enforcement of hygiene standards. Additionally, the facility did not maintain the required temperature for milk during meal service. Milk cartons were found to be at 44.5 degrees Fahrenheit, above the required 41 degrees, after being left on a metal tray with ice for 15 minutes. The Corporate Dietary Consultant confirmed the temperature issue, and the Administrator was unaware of this lapse. Furthermore, the kitchen ceiling was observed to have peeling paint and drywall, posing a risk of physical contamination. The Maintenance Manager acknowledged the issue but had not addressed it despite being informed a week prior. The Administrator was also unaware of the ceiling's condition, indicating a lack of timely maintenance and communication within the facility.
Repeated Deficiencies in QAPI Program
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain effective procedures and monitor interventions following a recertification survey, resulting in repeated deficiencies. Specifically, the facility did not provide a clean, home-like environment in the main dining room, as evidenced by a dirty, sticky floor and a dirty window, and failed to repair a leaking roof. Additionally, the facility did not clean the Packaged Terminal Air Conditioner (PTAC) units in residents' rooms. The facility also failed to act on a hospital discharge order for a nephrology follow-up appointment for a resident and did not follow up on laboratory results for another resident reviewed for urinary tract infections (UTIs). Furthermore, medications were left unsecured and accessible to unauthorized staff and residents, and multi-use medications were not dated upon opening. Expired multi-dose inhalers were not discarded, and protein supplements were not dated. Lastly, the facility failed to provide dependent residents with proper nail care and ensure a resident was free from unwanted facial hair. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. The deficiencies were identified through observations, record reviews, and interviews with residents and staff. The Administrator attributed the repeat citations to staff turnover during the pandemic. The deficiencies were cross-referenced to specific tags, including F584, F690, F761, and F677, highlighting issues in maintaining a safe, clean, and comfortable environment, quality of care, proper medication storage, and quality of life for residents.
Failure to Provide Dietary Supplements as Ordered
Penalty
Summary
The facility failed to provide dietary supplements as ordered for two residents, leading to deficiencies in their nutritional care. Resident #84, who had diagnoses including dementia and severe malnutrition, was prescribed a high-calorie Magic Cup twice daily. However, observations on two consecutive days revealed that the Magic Cup and a soft sandwich were missing from her meal trays. Interviews with staff indicated that the dietary items were either forgotten or mistakenly believed to be out of stock, despite being available in the kitchen. The Dietary Manager confirmed that the items should have been included on the meal trays, and the oversight was attributed to human error during meal preparation. Resident #67, admitted with a fractured left humerus and underweight, was prescribed a house supplement and fortified pudding to address her inadequate oral intake. Observations showed that the fortified pudding was missing from her meal trays on two separate days. Interviews revealed that the dietary manager was unaware of the order for fortified pudding, and the order had been inaccurately entered into the electronic medical record. As a result, Resident #67 did not receive the prescribed fortified pudding, contributing to her continued weight loss. Both residents had documented weight loss and poor oral intake, which were not adequately addressed due to the facility's failure to provide the ordered dietary supplements. Interviews with the physician and other staff confirmed that the supplements were expected to be provided as ordered to support the residents' nutritional needs. The deficiencies were attributed to lapses in communication and oversight in the dietary department, leading to the residents not receiving the necessary nutritional support as prescribed.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents. A nurse left medications at the bedside of a resident with moderate cognitive impairment, who did not have an order to self-administer medications. The medications were left unattended for an extended period, and the nurse admitted to forgetting to return to administer them after attending to another resident. The Director of Nursing (DON) confirmed that medications should not be left at the bedside unless there is an order for self-administration. Additionally, the facility failed to date multi-use medications upon opening in two medication carts. Observations revealed that multi-dose medications in the 400 Hall and 500 Hall medication carts were not dated upon opening, contrary to manufacturer recommendations. Nurses verified the medications were not dated and discarded them. The Assistant Director of Nursing (ADON) and other nursing staff acknowledged the requirement to date multi-dose medications but admitted to lapses in compliance. Interviews with the DON and other nursing staff highlighted a lack of adherence to protocols for securing and dating medications. The DON stated that nurses should date multi-dose medications upon opening and check for dates daily prior to administration. However, a new nurse on the 500 Hall was unaware of the requirement to date multi-use packages, indicating a gap in training and communication within the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Biscoe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forrest Oakes Healthcare | 20.9 mi | ★★★★★ | 5 | 0 |
| Peak Resources - Pinelake | 21.2 mi | ★★★★★ | 1 | 0 |
| The Greens At Pinehurst Rehabilitation & Living Ce | 21.4 mi | ★★★★★ | 11 | 0 |
| Saint Joseph Of The Pines Health Center | 22 mi | ★★★★★ | 9 | 0 |
| Trinity Place | 22.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.