Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Care Of Raeford during CMS and state inspections, most recent first.
Surveyors observed that a nurse administered an 81 mg enteric-coated aspirin instead of the ordered 81 mg chewable aspirin and failed to administer ordered polyethylene glycol 3350 to a cognitively intact resident, contributing to 2 errors out of 30 opportunities and a medication error rate above 5%. The nurse reported she did not notice the aspirin formulation difference and chose not to offer the polyethylene glycol because the resident usually refused it, while the resident stated he typically has regular bowel movements and would notify staff if that changed.
A resident admitted for respite care with diabetes did not receive prescribed Lantus insulin or have blood glucose monitored due to failure by nursing staff to accurately transcribe physician orders from the FL2 form into the EHR. Multiple nurses relied on incomplete records and did not verify orders or medications, resulting in the resident being discharged with dangerously high blood glucose, requiring EMS intervention and emergency department care.
A resident with limited range of motion and contractures did not have a left hand splint applied as ordered, despite being observed multiple times without it. The Restorative Aide was unaware of the requirement, and the Occupational Therapist later found and applied the hand roll. The DON and Administrator confirmed the expectation for staff to follow the order, which was not met.
A cognitively impaired female resident was sexually abused by a male visitor who was visiting another resident. The incident was observed by a Nursing Assistant (NA) who saw the visitor leaning over the resident. The visitor admitted to inappropriate touching. Discrepancies in staff accounts and lack of a care plan addressing sexual behaviors for the resident were noted. The facility's response included reporting to law enforcement and the State agency. The investigation confirmed the deficiency through staff interviews, law enforcement involvement, and medical assessments.
Medication Pass Errors Result in Exceeding 5% Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 30 medication administration opportunities, resulting in a 6.67% error rate. For one cognitively intact resident receiving medications for DVT prevention and constipation, review of physician orders showed a prescription for aspirin 81 mg chewable once daily and polyethylene glycol 3350 powder 17 g once daily. During a medication pass observation, a nurse removed and administered an 81 mg enteric-coated aspirin tablet from a stock bottle instead of the ordered chewable aspirin. The nurse later stated she did not notice that the aspirin she selected was enteric-coated rather than chewable. During the same observed medication pass, the nurse did not administer the ordered polyethylene glycol 3350, 17 g, to the same resident. In interview, the nurse explained that she did not give the polyethylene glycol because the resident typically refused it and she did not see the need to ask if he wanted the medication at that time. The resident reported that he moved his bowels every day to every other day and would inform nursing staff if he did not have a bowel movement within that timeframe. The DON stated an expectation that nurses administer medications according to physician orders, and the MD stated she expected nurses to look closely at the MAR and administer the medications as ordered.
Failure to Transcribe and Implement Diabetes Management Orders for Respite Admission
Penalty
Summary
A deficiency occurred when a facility failed to accurately transcribe and implement physician orders for a resident admitted for respite care with a history of type 2 diabetes, dementia, hypertension, and chronic kidney disease. The resident's FL2 form, completed by the primary care provider, included orders for Metformin, Empagliflozin, Lantus insulin (5 units at bedtime), and continuous glucose monitoring. However, during the transcription of these orders into the electronic health record (EHR), the orders for Lantus and blood glucose monitoring were omitted. Multiple nurses involved in the admission and care process did not verify the FL2 orders against the EHR or the medications brought in by the responsible party, resulting in the resident not receiving Lantus or having blood glucose monitored during the entire stay. Staff interviews revealed that the nurse initially responsible for transcribing the orders was unsure why the Lantus and glucose monitoring orders were not entered. The admitting nurse relied on the previously transcribed orders and did not check the FL2 form for accuracy, nor did she verify the medication bag contents thoroughly. Subsequent nursing staff followed the medication administration record (MAR) and did not administer Lantus or perform blood glucose checks, as these were not listed in the EHR. None of the staff noticed or inquired about the resident's continuous glucose monitoring device, and no one contacted the provider for clarification regarding the missing orders or the absence of the monitoring device. As a result, the resident did not receive prescribed insulin or have blood glucose monitored during the respite stay. After discharge, the responsible party discovered the resident's blood glucose was critically high, administered Lantus, and contacted EMS. The resident was subsequently transferred to the emergency department with hyperglycemia, elevated heart rate, and diarrhea, and was treated with intravenous fluids. The omission of critical diabetes management orders directly led to the resident's acute medical episode following discharge.
Removal Plan
- Resident #1's case was investigated by the Director of Nursing (DON), including staff interviews, surveillance footage review, and chart audit to determine the omission of insulin and blood glucose monitoring orders.
- DON contacted Resident #1's Responsible Party (RP) to inform her of the investigation findings and provided education on signs and symptoms of hypo/hyperglycemia and when to call emergency services.
- DON audited all respite residents admitted, comparing FL2 forms and EHR orders to identify discrepancies.
- Discrepancies found in other residents were addressed by verifying home medications with the RP and notifying the provider for clarification and new orders.
- DON provided verbal education to all nurses regarding omission of admission orders for respite residents.
- Facility will continue to obtain an FL2 prior to offering respite admission.
- Admissions Director will continue to communicate with RPs that home medications are required upon arrival.
- All nurses instructed to use the FL2 to transcribe orders into the EHR and compare medication bottle labels with EHR orders upon admission.
- If discrepancies are found, the assigned nurse will contact the family to determine the current medication regimen and notify the provider for clarification.
- If the family cannot be reached, the nurse will contact the provider for clarification of orders.
- If medications are not provided by the RP upon admission, the nurse will contact the provider and obtain medications from the facility's contracted pharmacy.
- All newly hired nurses (facility, agency, contract) will receive verbal education on transcription of respite resident orders before training on the floor.
- DON or designated nursing supervisor will audit respite residents, physically observing home medications and ensuring accurate transcription of all orders.
- DON or designee will compare EHR orders to each resident's FL2 and home medications on the day of admission for each respite resident.
- Daily audits will be completed and reviewed at the next scheduled QAPI meeting.
- ADHOC QAPI review was completed by the DON.
Failure to Apply Ordered Hand Splint for Resident
Penalty
Summary
The facility failed to apply a left hand splint as ordered for a resident with limited range of motion and contractures. The resident, who was moderately cognitively impaired and dependent on assistance for personal care, had an occupational therapy order for a left hand roll with finger separators to be worn at all times except during hand hygiene. Despite this order, the resident was observed on multiple occasions without the splint, and the left hand was noted to be contracted. Interviews with staff revealed a lack of understanding and execution of the order. The Restorative Aide responsible for the resident's care was unaware of the requirement to apply a splint or finger separators, believing instead that a rolled washcloth was to be used. The Occupational Therapist confirmed the importance of the splint in preventing worsening contractures and skin breakdown, and found the hand roll in the resident's room, applying it only after the oversight was discovered. The Director of Nursing and the facility Administrator both acknowledged the expectation for nursing staff to follow the physician's order, which was not met in this case.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Visitor
Penalty
Summary
The facility failed to protect a cognitively impaired female resident (Resident #1) from sexual abuse by a male visitor on 03/28/24. The incident occurred when the Visitor, who was at the facility visiting his family member (Resident #2), entered Resident #1's semi-private room on the secured dementia unit. A Nursing Assistant (NA) observed the Visitor leaning over Resident #1 with his back to the door, and upon questioning, the Visitor admitted to touching Resident #1's vagina. Resident #1, who was incapable of giving consent, expressed fear and discomfort following the incident. The facility's failure to protect Resident #1's right to be free from abuse was evident in the lack of appropriate care plan related to sexual behaviors for Resident #1, despite her admission with diagnoses including dementia and behavioral disturbances. The deficiency was further highlighted by discrepancies in staff accounts of the incident. Initially, NA #1 reported witnessing the Visitor adjusting his pants and tucking his penis back in, but later clarified in an addendum that she did not actually see his penis. The Director of Nursing (DON) also noted discrepancies in staff statements regarding the observation of the Visitor's actions. The facility's response to the incident, including reporting to law enforcement and the State agency, indicated a reactive rather than proactive approach to resident safety and abuse prevention. The investigation revealed further details of the incident, including interviews with staff, law enforcement involvement, and medical assessments of Resident #1 post-incident. The Visitor's confession to law enforcement, Resident #1's statements of being hurt and scared, and the subsequent medical examinations all contributed to the confirmation of the deficiency in protecting Resident #1 from sexual abuse within the facility. The lack of appropriate care planning, staff training, and immediate response to the incident underscored the facility's failure to ensure the safety and well-being of its residents, particularly those vulnerable to abuse due to cognitive impairments.
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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 Raeford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Care Of Fayetteville | 13 mi | ★★★★★ | 1 | 0 |
| Dahlia Gardens Center For Nursing And Rehabilitati | 14.2 mi | ★★★★★ | 6 | 0 |
| Carolina Rehab Center Of Cumberland | 15.1 mi | ★★★★★ | 1 | 0 |
| Penick Village | 15.4 mi | ★★★★★ | 3 | 0 |
| Village Green Health And Rehabilitation | 17.5 mi | ★★★★★ | 3 | 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 August 2026) and official state health department websites.