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 Shallotte during CMS and state inspections, most recent first.
A nurse administered subcutaneous fluids to the wrong resident after confusing two roommates and using the incorrect resident’s profile in the automated dispensing system. She later stopped the infusion and started the fluids on the correct resident, but did not assess the affected resident or notify the MD, resident, or responsible party. The resident later reported the incident, and the responsible party and MD stated they had not been informed.
A nurse misidentified two roommates and started ordered subcutaneous fluids on the wrong resident after removing the fluids from the ADC under the incorrect profile. The nurse later realized the error, stopped the infusion, and started the fluids on the correct resident. The resident who received the fluids in error later reported abdominal pain during placement of the device, and the NP documented an accidental medication error involving hypodermoclysis.
A pharmacy failed to promptly notify staff of a high-priority medication discrepancy for a resident recently discharged from the hospital with pneumonia and sepsis. As a result, the resident did not receive prescribed antibiotics for several days until the issue was identified and corrected, due to the pharmacy's lack of timely communication and failure to follow its own urgent notification procedures.
Surveyors found that staff did not label or date opened food packages in the kitchen walk-in cooler and failed to remove expired gelatin cups from a nutrition room. The Dietary Manager and Administrator confirmed that these practices did not meet facility expectations for food storage and safety.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
A nurse in an LTC facility failed to administer several medications, resulting in a 16% medication error rate. The nurse omitted Budesonide, Sennosides-Docusate Sodium, MiraLAX, and Aspirin for a resident, initially claiming to have given the Budesonide earlier. The nurse withheld constipation medications without consulting the resident, based on outdated information. The DON confirmed the nurse should have assessed the resident's current condition and obtained a physician's order if needed.
A resident with atrial fibrillation and hypomagnesemia did not receive prescribed Metoprolol and Magnesium Oxide due to a failure in entering medication orders into a new electronic medical record system during a transition period. The orders were not documented in the MAR, and staff were unaware of the need to enter orders into both old and new systems. Despite the oversight, the resident's heart rate and blood pressure remained stable, and there was no significant outcome from the missed medications.
The facility failed to maintain proper sanitizing solutions in the kitchen and did not date refrigerated food items. The sanitizing solution used for food preparation surfaces was below the recommended strength, and containers of tuna salad, ham salad, and fortified chocolate pudding in the walk-in refrigerator were not labeled with opened or end dates. This could potentially affect the quality and safety of food served to residents.
A resident slapped another resident in the face, but the incident was not immediately reported to the Administrator as required by the facility's abuse policy. Nurse #7 observed the incident and informed Nurse #8, but neither reported it to the Administrator, leading to a delay in addressing the situation. The Administrator was only informed the next day by another nurse reviewing clinical records.
A nurse inaccurately documented the administration of medications in the eMAR for a resident, failing to administer Budesonide, Sennosides-Docusate Sodium, MiraLAX, and Aspirin as ordered. The nurse admitted to signing off the medications as given without actually administering them, citing convenience as a reason for the inaccurate documentation.
The facility failed to limit PRN psychotropic medication orders for two residents to 14 days or document a rationale for continued use. One resident received lorazepam without a stop date, while another had an active order without administration. The issue was acknowledged by the facility's staff, including the DON and Medical Director, but remained unresolved.
Failure to Notify Physician and Responsible Party After Wrong-Resident Fluid Administration
Penalty
Summary
The facility failed to notify the resident’s physician and responsible party after a treatment error in which Resident #2 received subcutaneous fluids that had been ordered for her roommate, Resident #4. Resident #2 was admitted with end stage renal disease, was cognitively intact, and received dialysis. The error involved sodium chloride 0.9% solution ordered for Resident #4 to be administered subcutaneously at 70 milliliters per hour. According to the nursing statement and interview, Nurse #1 wrote the order on paper, removed the fluids from the automated dispensing system under Resident #2’s profile, and initiated the hypodermoclysis infusion in Resident #2’s mid-abdomen. She later realized the order was for Resident #4, stopped the infusion for Resident #2, removed the device, and then started the fluids on the correct resident. Nurse #1 stated that she did not assess Resident #2 and did not notify the physician, Resident #2, or the responsible party about the error. Resident #2 later reported the incident to the Unit Manager and DON, stating that a nurse had inserted a needle into her abdomen and started fluids before discontinuing them. The DON documented that the provider was informed of the error, and a nurse practitioner later assessed Resident #2 after the accidental administration error. The responsible party stated she had not been notified of the event, and the physician stated she had not been informed and expected immediate notification for further assessment, monitoring, and orders.
Wrong Resident Received Ordered Subcutaneous Fluids
Penalty
Summary
The facility failed to ensure that subcutaneous fluids were administered in accordance with the physician's order for one resident. Resident #2 was admitted with diagnoses including end stage renal disease, hypertensive heart disease, and diabetes, and the quarterly MDS indicated the resident was cognitively intact and received dialysis. Resident #4 had a physician order for one liter of 0.9% sodium chloride to be administered subcutaneously at 70 mL per hour. A nurse received the order for Resident #4 but wrote it on a piece of paper and then removed the fluids from the automated medication and supply dispensing system under Resident #2's profile. The nurse then entered Resident #2's room and initiated the hypodermoclysis in Resident #2's mid-abdomen. The nurse later realized the order was for Resident #4, returned to Resident #2, stopped the infusion, removed the device, and then initiated the fluids on Resident #4. The nurse reported that the day was hectic, she was overwhelmed by interruptions, and she often confused the two roommates. Resident #2 later reported that she had been stuck in the abdomen and received fluids intended for her roommate, and the Nurse Practitioner documented an accidental medication error involving subcutaneous normal saline. Resident #2 reported lower abdominal pain during placement of the device and had recently undergone hernia repair surgery. An abdominal x-ray was obtained and showed no acute abnormalities. The nurse did not assess Resident #2 or notify the provider, resident, or responsible party at the time of the error, and the physician later stated she had not been informed of the incident.
Failure to Promptly Notify Facility of High-Priority Medication Discrepancy
Penalty
Summary
A deficiency occurred when the pharmacy failed to promptly notify facility staff of a high-priority clinical recommendation regarding a resident's antibiotic orders following hospital discharge for sepsis due to pneumonia. The resident, who had chronic respiratory failure with hypoxia, congestive heart failure, and COPD, was discharged from the hospital with orders to continue antibiotics (cefdinir and doxycycline) for pneumonia. The pharmacy's medication review identified that these antibiotics were not active in the facility's computer system and that the current hospital discharge orders had not been re-entered, but this information was not communicated to the facility in a timely manner. Although the pharmacy's policy required that priority recommendations be called in for immediate response, there was no evidence that the facility was notified by phone. The pharmacy consultation report was sent via email and not seen by the Director of Nursing until several days later, resulting in the resident not receiving the prescribed antibiotics from the time of readmission until the orders were clarified and entered. Interviews with facility staff and the consultant pharmacist confirmed that the lack of timely notification contributed to the delay in administering necessary medications.
Failure to Label, Date, and Discard Expired Food Items
Penalty
Summary
The facility failed to properly label and date opened food packages in the kitchen walk-in cooler and did not discard expired food items in a nutrition room. During an initial kitchen tour, surveyors observed an opened package of French toast sticks and an opened package of cauliflower in the walk-in cooler without any labels indicating the date they were opened or their expiration dates. In a separate observation of a nutrition room, surveyors found multiple cups of sugar-free orange gelatin with expiration dates that had already passed. Interviews with the Dietary Manager confirmed that all opened foods should be labeled and dated, and that expired foods should not be present in nutrition rooms. The Administrator also stated that staff are expected to check for and discard expired food and to label and date stored food.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 16%. During a medication administration pass, a nurse omitted several medications for a resident, including Budesonide nebulizer treatment, Sennosides-Docusate Sodium, MiraLAX, and Aspirin. The resident, who was cognitively aware, was observed receiving other medications but not the omitted ones. The nurse initially claimed to have administered the Budesonide earlier due to the resident's shortness of breath, but later retracted this statement. The nurse also held the Sennosides and MiraLAX without consulting the resident, based on an assumption from a previous condition of loose stools. The nurse did not verify if the resident still experienced this condition before withholding the medications. The Director of Nursing (DON) confirmed that the nurse should have assessed the resident's current condition and obtained a physician's order if the resident requested to hold the medications. Additionally, the nurse missed administering Aspirin, which was not on the list of medications given during the observed pass. Upon realizing the omission, the nurse prepared to administer the Aspirin and inquired if the resident wanted the previously held medications, which the resident refused. The DON and Regional Clinical Director (RCD) noted the nurse's failure to follow the physician's orders and the need for further education on the five rights of medication administration.
Medication Administration Deficiency During EMR Transition
Penalty
Summary
The facility failed to implement physician orders for Metoprolol and Magnesium Oxide for a resident diagnosed with atrial fibrillation, congestive heart failure, and hypomagnesemia. The orders, dated 05/04/24, prescribed Metoprolol 12.5 mg twice a day and Magnesium Oxide 400 mg twice a day. However, a review of the Medication Administration Record (MAR) and progress notes from 05/04/24 through 08/28/24 revealed no documentation of these medications being administered to the resident. The deficiency occurred during a transition to a new electronic medical record system. The Regional Director of Clinical Services explained that during the transition period, staff were instructed to enter new medication orders into both the old and new systems. However, it appears that the orders for Metoprolol and Magnesium Oxide were not entered into the new system, leading to the medications not being administered. Nurse #13, who worked per diem, stated she was not aware of the requirement to enter orders into both systems and did not recall entering the orders for the resident. Interviews with the Medical Director and Consultant Pharmacist indicated that the resident's heart rate and blood pressure were well controlled, and there was no significant outcome from not receiving the medications. The Medical Director noted that the Metoprolol was a low-dose trial for additional protection, and the Magnesium Oxide was a supplement. The Consultant Pharmacist suggested that the Metoprolol might not be necessary due to the resident's stable condition and existing anticoagulant therapy.
Deficiency in Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper sanitizing solutions in the kitchen and did not ensure that refrigerated food items were dated. During an initial tour of the kitchen, it was observed that the sanitizing solution used to wipe down food preparation tables registered 0 parts per million (PPM) of quaternary sanitizer, which is below the recommended strength of 200-300 PPM. The dietary staff did not check the strength of the sanitizing solution when it was prepared, leading to inadequate disinfection of food preparation surfaces. The Dietary Manager confirmed that the solution should have been tested and maintained at the appropriate strength throughout the day. Additionally, during a follow-up observation of the kitchen's walk-in refrigerator, it was found that containers of tuna salad, ham salad, and fortified chocolate pudding were not labeled with opened or end dates. The Dietary Manager was unable to explain why these items were not dated properly, although she stated that she monitored the refrigerators and freezers weekly. The lack of proper dating on food items stored in the refrigerator could potentially affect the quality and safety of the food served to residents.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy when an incident of resident-to-resident abuse occurred. Specifically, the policy required staff to immediately report any allegations of abuse to the Administrator or Abuse Coordinator. However, this protocol was not followed when Resident #57 slapped Resident #83 on the face. The incident was observed by Nurse #7, who separated the residents and assessed Resident #83 for injuries, finding none. Despite taking these immediate actions, Nurse #7 did not report the incident to the Administrator, assuming that her supervisor, Nurse #8, would do so. Nurse #8, upon being informed of the incident by Nurse #7, instructed her to document the occurrence and maintain a 15-minute check on Resident #57. However, Nurse #8 also failed to report the incident to the Administrator or the Director of Nursing (DON), as she forgot to instruct Nurse #7 to do so. This oversight resulted in a delay in reporting the incident to the facility management, as the Administrator only became aware of the situation the following day when Nurse #9 reviewed the clinical records and reported it. The facility's policy, revised on 08/30/23, clearly stated that any allegations of abuse must be reported immediately to the Administrator or Abuse Coordinator, who would then initiate an investigation and notify the relevant local and state agencies. The failure of both Nurse #7 and Nurse #8 to adhere to this policy resulted in a delay in addressing the incident, which was only reported to the Department of Health and Human Services (DHHS) the day after it occurred.
Removal Plan
- Counseling and education was done by the Director of Nursing with the two employees that failed to report timely.
- All staff were interviewed to ensure there were no additional cases of unreported abuse.
- The DON/Designee started abuse education with all staff. The training included in part; Resident to resident incidents are considered abuse and must be reported immediately, separate residents, report to supervisor, and call Administrator. All staff would be required to sign training signature sheet prior to their next shift.
- The DON/designee to ask 5-staff members a week who the abuse coordinator is and if they know what to do if they see abuse including resident to resident abuse allegations. Facility Administrator or designee will conduct an audit to ensure that staff know what to do for abuse and who the abuse coordinator is.
- Results will be reviewed at facility's QAPI meetings for the duration of the audits including monitoring to ensure staff reported abuse allegations within the required timeframe.
- An ad hoc QAPI meeting was completed with the interdisciplinary team. The Medical Director was notified by the Administrator.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to accurately document the administration of medications in the electronic medical administration record (eMAR) for a resident during a medication pass observation. The resident, who was cognitively aware, was observed during a medication pass conducted by a nurse. The nurse indicated that she had completed the medication pass and administered all medications as ordered. However, upon review, it was found that the nurse had omitted administering several medications, including Budesonide Suspension nebulizer, Sennosides-Docusate Sodium, MiraLAX, and Aspirin, despite having signed off on the eMAR that these medications were given. The nurse admitted to not administering the Budesonide nebulizer treatment and inaccurately documenting it as given. She also held the Sennosides and MiraLAX due to the resident's previous loose stools but signed them off as administered for convenience. Additionally, the nurse omitted the administration of Aspirin but signed it off as given. The Director of Nursing expressed that the expectation was for accurate documentation to ensure proper medication administration as ordered by the physician.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders for two residents were limited to 14 days or documented with a rationale and duration for continued use. Resident #45, who was admitted with age-related cognitive decline and moderate dementia with anxiety, had a PRN order for lorazepam 0.5 mg every 8 hours as needed, without an end date or rationale documented. Despite receiving 16 doses of lorazepam in August 2024, the facility did not address the lack of a stop date, as highlighted by the Consultant Pharmacist's recommendation to discontinue or document the medication's use. Interviews with the Director of Nursing and the Medical Director revealed a lack of oversight in ensuring compliance with the 14-day limit for PRN psychotropic medications. Similarly, Resident #21, admitted with vascular dementia and anxiety, had an active PRN order for lorazepam 0.25 mg every 12 hours as needed, which also lacked a stop date. Although the medication was not administered, the absence of a stop date was noted in the Consultant Pharmacist's review. Interviews with the Medical Director and the Director of Nursing, along with the Regional Director of Clinical Services, acknowledged the issue of missing 14-day stop dates for PRN psychotropic medications. The facility recognized the problem and planned to address it, but the deficiency remained uncorrected at the time of the report.
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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 Shallotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brunswick Health & Rehab Center | 9.2 mi | ★★★★★ | 7 | 0 |
| Brunswick Rehabilitation And Healthcare Center | 9.5 mi | ★★★★★ | 9 | 0 |
| Liberty Commons Nursing & Rehab Center Of Southpor | 21.4 mi | ★★★★★ | 1 | 0 |
| Premier Living And Rehab Center | 24.9 mi | ★★★★★ | 0 | 0 |
| Brunswick Cove Nursing Center | 27 mi | ★★★★★ | 15 | 0 |
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