Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Cornelius during CMS and state inspections, most recent first.
Staff failed to provide menu-specified food items to residents on regular and puree diets, substituting noodles for mixed vegetables without RD approval and omitting puree bread for those on modified diets. These actions occurred without notifying supervisors or ensuring nutritionally equivalent alternatives, affecting multiple residents on one unit.
A resident with GERD was found to be self-administering antacid tablets kept at bedside without a current assessment or physician order authorizing self-administration. Nursing staff were unaware of the medication's presence, and the DON confirmed that required assessments and orders had not been completed.
A resident was not protected from the wrongful use of their belongings or money, as facility staff failed to safeguard personal property or funds, resulting in unauthorized or improper use.
A nurse failed to use sterile technique while suctioning a resident's tracheostomy, instead using clean gloves and not following sterile procedure, despite being aware of the correct protocol. Interviews with the DON and Administrator confirmed that sterile technique was expected for this procedure.
Surveyors identified that the medication error rate in the facility was 5 percent or greater, indicating that medication administration was not performed with sufficient accuracy and exceeded regulatory standards.
Three bottles of Nystatin medicated powder were repeatedly observed unsecured on a resident's dresser, despite the resident being severely cognitively impaired and requiring assistance with transfers. Nursing staff and the DON confirmed that the medication should have been stored in the treatment cart unless a physician's order specified otherwise, but no such order existed.
A resident with diabetes, who was able to communicate her needs, repeatedly received food items she disliked, such as grits, despite informing the dietary department of her preferences. Her meal tray ticket did not reflect her dislikes, and she did not receive a requested banana. Both the DM and administrator confirmed that resident preferences should be honored, but the facility failed to accommodate the resident's communicated food choices.
A nurse aide did not remove dirty gloves or perform hand hygiene during and after providing incontinence care to a resident, instead continuing to perform multiple care tasks and handle items in the resident's environment before finally removing gloves and leaving the room without hand hygiene. Interviews confirmed that this practice did not align with facility policy or leadership expectations.
The facility did not provide pharmaceutical services to meet residents' needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
The facility failed to prevent urinary catheter bags from touching the floor for two residents, leading to potential infection risks. Despite staff awareness, the catheter bags were repeatedly found on the floor, highlighting a lack of proper attachment options and consistent monitoring.
The facility failed to ensure controlled substances were securely stored, did not date an open vial of insulin, and failed to date and discard Tuberculin serum after 30 days in two medication rooms. The DON and staff confirmed these lapses in following facility policies.
The facility failed to serve palatable food, as multiple residents reported that the beef stir fry served for lunch was too salty to eat. The cook used an excessive amount of soy sauce, and the Administrator had not conducted test trays or tasted the food, leading to widespread dissatisfaction among residents.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeat deficiencies in Resident Assessment and Pharmacy Services. Specifically, the facility did not complete CAAs comprehensively for two residents and failed to ensure the safe storage and proper dating of medications.
A resident was found self-administering a nasal spray, pain patches, and an inhaler without proper assessment or orders. The DON confirmed that all medications should have been assessed and ordered, highlighting a deficiency in the facility's medication management.
The facility failed to complete comprehensive Care Area Assessments (CAAs) for two residents, leading to deficiencies in addressing their underlying causes and contributing factors. One resident with depression and another with Alzheimer's and psychotic disorder had CAAs that lacked detailed information about their needs and conditions.
The facility failed to develop a care plan for a resident with a urinary catheter. The resident's care plan and MDS assessment did not reflect the presence of the catheter, despite physician orders and a urology consult indicating its necessity. The responsibility fell to an MDS Nurse who was unaware of the catheter placement due to the absence of the primary MDS Nurse.
Failure to Follow Approved Menu and Provide Appropriate Food Substitutes
Penalty
Summary
The facility failed to provide food items as specified by the approved menu for residents on both regular and puree diets. On the specified date, residents on a regular diet were supposed to receive chili and beans, garden salad with dressing, cornbread, and carrot cake, with mixed vegetables and noodles as alternate items. However, the garden salad was not served due to improper temperature, and mixed vegetables were substituted. When mixed vegetables ran out, noodles were served instead, without consulting the Registered Dietitian (RD) or supervisor. The dietary aide admitted to frequently running out of food and plating whatever was available without notifying supervisors or seeking guidance for nutritionally equivalent substitutes. The RD and Administrator confirmed that noodles were not an appropriate substitute for mixed vegetables and that the dietary aide should have waited for an appropriate substitute. Additionally, residents on a puree diet did not receive puree bread or a substitute, as required by the menu. The RD confirmed that no puree bread was available for the meal, and the dietary aide did not notify supervisors about the missing item. It was later revealed that puree bread had been prepared but was not delivered to the appropriate hall. The Administrator acknowledged that residents on a puree diet did not receive bread as specified by the menu. These failures affected multiple residents on one unit and were confirmed through observations, record review, and staff interviews.
Failure to Reassess and Authorize Resident Self-Administration of Medication
Penalty
Summary
A resident with a diagnosis of gastroesophageal reflux disease (GERD) was admitted to the facility and had a physician's order for calcium carbonate chewable tablets to be taken as needed for GERD symptoms. The resident's self-administration assessment indicated she did not wish to self-administer medications, and her annual MDS assessment showed she was cognitively intact. Despite this, observations over several days revealed a bottle of antacid tablets at the resident's bedside, which the resident stated had been brought by a family member and that she took as needed for heartburn, particularly at night. Nursing staff were unaware that the resident had the medication at her bedside and that she was self-administering it. The nurse interviewed stated there was no order for the resident to self-medicate and did not believe the resident was able to administer her own medications. The Director of Nursing confirmed that residents must be assessed and have a physician's order to keep medications at bedside and self-administer, which had not occurred in this case.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or improper use. Specific actions or omissions by facility staff led to this breach, directly impacting the resident's rights and property. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Use Sterile Technique During Tracheostomy Suctioning
Penalty
Summary
Nurse #7 failed to use sterile technique while suctioning a resident's tracheostomy. During a continuous observation, the nurse provided tracheostomy care to a resident who was cognitively intact and had a history of pneumonia and respiratory failure. When the resident indicated a need for suctioning, Nurse #7 discontinued care, removed her gloves, washed her hands, applied clean gloves, and proceeded to suction the tracheostomy using a sterile suction catheter. However, she did not don sterile gloves or maintain sterile technique during the procedure. In a subsequent interview, Nurse #7 confirmed she did not use sterile gloves or sterile technique, acknowledging awareness of the proper tracheostomy suction kits but attributing her lapse to nervousness. Both the DON and the Administrator stated their expectations that sterile technique be used for tracheostomy suctioning and that facility policy be followed. The deficiency was identified for one resident reviewed for tracheostomy care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on the surveyors' findings regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Unsecured Medicated Powder Left in Resident Room
Penalty
Summary
Surveyors observed that three bottles of Nystatin medicated powder were left unsecured on top of a resident's dresser over multiple days. The resident, who was admitted with obstructive uropathy and macular degeneration, was assessed as severely cognitively impaired and required partial to moderate assistance with transfers. Despite these conditions, the medicated powders remained accessible in the resident's room without being stored in a locked compartment as required. Interviews with nursing staff and the DON confirmed that medicated powders should be stored in the treatment cart unless there is a physician's order to keep them at the bedside. There was no such order for this resident. The DON and Administrator both acknowledged that the facility's policy was not followed, as the Nystatin powder was not secured and no authorization was present to leave it in the resident's room.
Failure to Honor Resident Food Preferences
Penalty
Summary
A resident with diabetes, who was cognitively intact and able to communicate her needs, had a physician order for a low concentrated sugar diet and a care plan that included honoring her dietary choices. Despite this, the resident repeatedly received food items she disliked, specifically oatmeal and grits, which she had informed the dietary department she would not eat. The resident expressed frustration about receiving these unwanted items, as she had been taught not to waste food and found it upsetting to receive meals she would not consume. Observations revealed that the resident's meal tray ticket did not document her food dislikes, and on one occasion, she did not receive a requested banana, which she stated was important to her. The Dietary Manager acknowledged that residents should not receive items they have asked to avoid and that all items listed on the tray ticket should be provided. The administrator also confirmed the expectation that residents' food preferences should be honored. Despite these expectations, the facility failed to ensure the resident's food preferences were accommodated as communicated.
Failure to Follow Hand Hygiene Protocol During Incontinence Care
Penalty
Summary
A nurse aide failed to follow the facility's infection control policy for hand hygiene during incontinence care for a resident. Continuous observation showed that the nurse aide, while wearing gloves, performed multiple tasks including cleaning urine, applying skin barrier ointment, repositioning the resident, and handling various items in the resident's environment without removing gloves or performing hand hygiene between tasks. The aide only removed gloves at the end of care, disposed of them, picked up the trash bag, and exited the room without performing hand hygiene after glove removal. Interviews with the nurse aide revealed that glove changes were only performed if gloves were visibly soiled, and hand hygiene was typically done when exiting the resident's room. The Director of Nursing, Administrator, and Infection Preventionist all stated that their expectation was for staff to remove gloves and perform hand hygiene when moving from dirty to clean tasks, after incontinence care, and before continuing with other care activities. The facility's policy also required hand hygiene after glove removal and after contact with bodily fluids.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Catheter Bags from Touching the Floor
Penalty
Summary
The facility failed to prevent urinary catheter bags from touching the floor for two residents, leading to potential infection risks. Resident #17, who had a history of urinary retention and Parkinson's Disease, was observed multiple times with her catheter bag positioned on the floor while she was in her wheelchair. Despite staff being aware of the issue, the catheter bag was repeatedly found on the floor in various locations, including the dining room and activity room. Interviews with staff revealed a lack of proper attachment options for the catheter bag and a general unawareness of the bag's position, despite knowing the infection risks associated with it touching the floor. Resident #11, who had a history of urinary tract infections and was a fall risk, was also observed with her catheter bag resting on the floor due to her bed being in the lowest possible position. Staff interviews confirmed that they were aware of the catheter bag's position but did not take adequate measures to prevent it from touching the floor. The nurse assigned to Resident #11 acknowledged the issue but did not consistently ensure the catheter bag was off the floor, even though the Director of Nursing and the Administrator stated that catheter bags should never touch the floor. Both residents' care plans and physician orders indicated the need for proper catheter care, including keeping the catheter bag below the bladder and off the floor. However, the facility's failure to adhere to these guidelines resulted in multiple instances where the catheter bags were improperly positioned, posing a risk of infection to the residents. Staff interviews highlighted a lack of consistent monitoring and appropriate attachment solutions for the catheter bags, contributing to the observed deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure a controlled substance medication ordered for a resident was safely stored and secured using a double lock feature. An observation revealed that the medication room refrigerator did not have a lock device, and the permanently affixed container inside the refrigerator was also not secured. This container held Lorazepam, a Schedule IV controlled substance, prescribed for a resident. The Director of Nursing (DON) and a nurse confirmed that the lock had been broken for months and had not been properly reported or fixed, leading to unsecured storage of the controlled substance. Additionally, the facility failed to date an open vial of insulin on one of the medication carts. During an observation, it was found that the vial of Humalog insulin had no date indicating when it was opened. The nurse interviewed was unsure of the opening date and stated she would discard the vial. The DON confirmed that staff were expected to date insulin vials when opened and that the insulin was good for 28 days after opening. The facility also failed to date and discard a vial of Tuberculin serum after 30 days in two medication rooms. Observations revealed one vial with an outdated opening date and another vial with no date at all. The DON confirmed that the Tuberculin serum should be discarded after 30 days and that the staff were expected to follow the facility policy for dating and discarding medications. The administrator reiterated the expectation for staff to adhere to these policies.
Facility Fails to Serve Palatable Food to Residents
Penalty
Summary
The facility failed to serve palatable food to residents, as evidenced by multiple complaints about the beef stir fry served for lunch. Seven residents, all cognitively intact and requiring set-up assistance with eating, reported that the beef stir fry was too salty to consume. These residents either did not eat the meal or had to find alternative food sources to satisfy their hunger. The issue was consistent across all interviewed residents, indicating a widespread problem with the meal's preparation and taste. The cook responsible for preparing the meal admitted to using a significant amount of soy sauce, which was not low sodium, and did not taste the dish after adding the soy sauce. The recipe called for 2 cups of soy sauce for 50 people, but the cook used 4.5 to 5 cups for 100 people, assuming it would balance out due to the larger portion size. This miscalculation led to the dish being excessively salty, making it unpalatable for the residents. An observation of a test tray confirmed the residents' complaints, with the rice being mushy and the beef stir fry being very salty. The Dietary Manager also found the dish too salty. The Administrator acknowledged receiving feedback from residents and had accumulated over 200 pictures of meals served but had not conducted test trays or tasted the food himself. This lack of direct oversight contributed to the ongoing issue with meal palatability.
Repeat Deficiencies in Resident Assessment and Pharmacy Services
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following the recertification and complaint survey conducted on 06/04/21. This failure resulted in repeat deficiencies in the areas of Resident Assessment (F636) and Pharmacy Services (F761) during the subsequent recertification and complaint investigation survey of 05/02/24. Specifically, the facility did not complete Care Area Assessments (CAAs) comprehensively to address the underlying causes and contributing factors for two sampled residents. Additionally, the facility failed to complete the Minimum Data Set (MDS) within 14 days of a resident's admission for one sampled resident during the previous survey. The facility also failed to ensure the safe storage and security of controlled substance medications, as well as proper dating and disposal of medications. One controlled substance medication was not secured using a double lock feature, and an open vial of insulin and Tuberculin Serum were not dated or discarded after 30 days as required. These issues were observed in multiple medication storage areas and carts. The Administrator confirmed that the QA committee met monthly and reviewed various data points, but the repeat deficiencies indicate an inability to sustain an effective QA program.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications. Resident #25, who was cognitively intact, had a physician's order for Fluticasone Propionate Nasal Suspension but no order for over-the-counter pain patches or an albuterol sulfate inhaler. The resident was observed using the nasal spray, pain patches, and inhaler without proper assessment or orders for the latter two medications. Nurse #1 had assessed the resident's ability to self-administer the nasal spray but was unaware of the resident's use of pain patches and an inhaler, which were kept in the resident's room without proper orders or assessments. The Director of Nursing (DON) confirmed that the resident should have been assessed for the ability to self-administer all medications kept in her room and that there needed to be orders for those medications. The DON also stated that staff needed to be educated to monitor medications at residents' bedsides. This oversight led to the resident self-administering medications without proper assessment and orders, which is a deficiency in the facility's medication management process.
Incomplete Care Area Assessments for Two Residents
Penalty
Summary
The facility failed to complete Care Area Assessments (CAAs) comprehensively for two residents, leading to deficiencies in addressing their underlying causes and contributing factors. Resident #67, who was admitted with a diagnosis of depression, had a CAA that lacked detailed information about his psychosocial needs, behaviors, medications, and how the facility would address these needs. The MDS Nurse responsible for completing the CAA admitted to only checking applicable boxes and proceeding to care planning without thorough elaboration, believing it was sufficient. The Director of Nursing (DON) expected the CAA to be comprehensive and thorough, which was not met in this case. Similarly, Resident #32, who had diagnoses including Alzheimer's disease, dementia, and psychotic disorder, had a significant change MDS assessment that triggered the care area of psychotropic drug use. However, the facility did not include detailed information in the analysis of findings, such as the resident's problems, possible causes, contributing factors, and risk factors related to the care area. The resident had a history of auditory hallucinations and paranoia, requiring antipsychotic medication, with previous gradual dose reductions failing. The MDS Nurse followed the same incomplete process as with Resident #67, and the DON reiterated the expectation for comprehensive and thorough CAAs. Interviews with the Psychiatric Nurse Practitioner and the Social Worker provided additional context about Resident #32's condition and treatment. The Psychiatric Nurse Practitioner noted the resident's need for antipsychotic medication due to auditory hallucinations and paranoia, while the Social Worker mentioned the resident's refusal to take medications and fixation on her roommate. Despite these observations, the CAA lacked the necessary detailed analysis, leading to the identified deficiency.
Failure to Develop Care Plan for Urinary Catheter
Penalty
Summary
The facility failed to develop a care plan for a resident with a urinary catheter. Resident #17, who was admitted with a diagnosis including urinary retention, had a urinary catheter inserted during a urology consult. Despite this, the resident's care plan, last reviewed on 04/24/24, did not include any focus on the urinary catheter. The resident's quarterly Minimum Data Set (MDS) assessment also did not reflect the presence of an indwelling urinary catheter, despite physician orders and a urology consult indicating its necessity. Interviews revealed that the responsibility for initiating the care plan fell to MDS Nurse #2, who was unaware of the catheter placement due to the absence of MDS Nurse #1, who normally attended clinical meetings. The Director of Nursing confirmed that the catheter should have been included in the care plan. Attempts to interview MDS Nurse #1 were unsuccessful, leaving the deficiency unaddressed at the time of the survey.
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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.
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Nursing homes near Cornelius
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Health & Rehab Center | 3.9 mi | ★★★★★ | 15 | 0 |
| Huntersville Health & Rehabilitation Center | 5 mi | ★★★★★ | 5 | 0 |
| Huntersville Oaks | 5.5 mi | ★★★★★ | 0 | 0 |
| The Citadel Mooresville | 7.1 mi | ★★★★★ | 0 | 0 |
| Crestview Health & Rehabilitation | 7.8 mi | ★★★★★ | 9 | 0 |
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