Below 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 Mechanicsville during CMS and state inspections, most recent first.
Staff failed to keep a dumpster lid closed, leaving trash bags exposed. The responsibility for maintaining the dumpsters was shared between dietary and maintenance departments, but the trash was not pushed down to allow the lid to close. Facility leadership was informed of the issue.
A resident with CHF and severe cognitive impairment did not have daily weights documented as ordered by the physician. Multiple dates showed missing weight entries in the eMAR and EHR, with no explanation provided by staff for the omissions, despite the importance of daily weights for CHF management.
A resident who experienced significant weight loss was not monitored according to physician orders, as daily weights were missed on multiple occasions. The resident, who was on a pureed diet and tube feeding, had a notable decrease in weight, and the RD had requested close monitoring. Staff cited time management and equipment uncertainty as reasons for not obtaining the required daily weights, despite facility policy and medical orders.
Staff failed to store opened food items in a sanitary manner by not sealing or dating them, and did not maintain required hot holding temperatures for several food items during meal service. Despite policy requiring food to be reheated if below 135°F, food was served at lower temperatures and not returned to the kitchen for reheating.
Facility staff did not complete or document required bed and bed rail safety inspections for four residents who used bed rails or positioning bars. Despite care plans indicating the need for these devices due to severe cognitive and physical impairments, inspection records were incomplete and staff acknowledged that the inspection process was not finished at the time of the survey.
A CNA was observed standing over a resident while feeding them, rather than sitting as required for a dignified experience. Staff interviews confirmed that sitting is the expected practice to ensure resident comfort and dignity, in line with facility policy.
Facility staff did not provide written notice to a resident before two room changes, despite facility policy requiring such notification. The resident expressed dissatisfaction with the new room, and staff interviews confirmed that written notice was not part of the current process. Review of records showed no documentation of written notification prior to the moves.
Facility staff did not inform a resident of the reason for a room transfer or document the notification, despite facility policy requiring both. The resident expressed dissatisfaction with the new room and was unaware of the reason for the move, which staff later attributed to a roommate conflict but failed to record.
Facility staff did not notify the physician when a resident with severe cognitive impairment refused ordered lab tests on two occasions. Although the refusal was recorded on lab logs, there was no documentation in the progress notes or evidence that the physician was informed, contrary to facility protocol.
A resident's quarterly MDS assessment was inaccurately coded to reflect the use of a restraint, specifically a chair that prevents rising, despite no documentation or observation supporting its use. The error was identified as a data entry mistake by the MDS coordinator.
Staff did not follow care plans for three residents, resulting in missed daily weights for a resident on enteral feeding and improper oxygen administration for two residents with respiratory conditions. One resident's weights were not obtained on several days due to time management and equipment confusion, while two others received oxygen at lower rates than ordered, despite clear care plan and physician instructions. Nursing staff acknowledged these discrepancies during interviews.
Staff did not update care plans for two residents to include physician-ordered adaptive eating equipment, orthotic devices, and interventions for significant weight loss. One resident was not provided with required adaptive utensils or a special cup despite documented needs and orders, and another was not offered a prescribed orthosis or adaptive utensils for a hand contracture. Care plans were not revised to reflect these needs, resulting in staff being unaware and the equipment not being used.
Facility staff did not clarify a physician order for a tracheostomy tube change for a resident who performed their own tracheostomy care. Although the order required a tube change every two months, documentation was lacking regarding who performed the procedure, and the LPN who signed off was unsure about the specifics. The facility's policy did not provide guidance on clarifying physician orders, and there was no evidence the order was clarified or the procedure documented.
A resident with diabetes, severe cognitive impairment, and multiple health conditions was observed with thick, overgrown toenails, and there was no evidence of recent foot care or podiatry visits. The resident stated that toenail care was not provided in the facility, and staff confirmed that residents with diabetes or thick nails are not given toenail care by nurses but should be referred to a podiatrist, with no documentation showing this was done.
A resident with a right-hand contracture was not consistently provided with a prescribed carrot orthotic device, despite an active order and occupational therapy recommendation for its daily use to prevent further contracture and skin breakdown. The device was present in the resident's room but not regularly offered, and the care plan lacked documentation of the need for the orthosis, indicating a failure to implement necessary interventions for range of motion and contracture management.
Staff failed to administer oxygen at the physician-prescribed rates for two residents requiring continuous oxygen therapy. In both cases, the oxygen concentrators were set below the ordered 4 liters per minute, contrary to facility policy and physician orders, as confirmed by staff interviews and direct observation.
Two residents with physician orders and therapy recommendations for adaptive eating equipment did not receive the prescribed devices during meals. One resident with hand tremors and ulnar drift was observed without a two-handled cup or foam utensil handles, while another resident with similar needs was left to use regular utensils and resorted to finger feeding. Staff were unaware of the residents' requirements, and care plans lacked necessary documentation, resulting in noncompliance with facility policy.
Dumpster Lid Left Open, Exposing Trash
Penalty
Summary
Facility staff failed to maintain one of two dumpsters in a sanitary manner by not ensuring that the lid was closed. During an observation, it was noted that the left lid of the right-side dumpster was left open, resting on a bag of trash, which resulted in the trash bags being exposed. Staff interviews confirmed that the responsibility for maintaining the dumpsters was shared between the dietary and maintenance departments, alternating monthly. The assistant dietary manager acknowledged that the trash should have been pushed down to allow the lid to close and that the lid should have been closed to prevent pest access. Further interviews with the director of environmental services confirmed the shared responsibility for dumpster maintenance and the frequency of trash removal. The director also agreed that the trash should have been managed to allow the lid to close. The deficiency was brought to the attention of facility leadership, including the administrator, director of nursing, and regional vice president of operations. No additional information was provided prior to the survey exit.
Failure to Follow Physician's Order for Daily Weight Monitoring in CHF Resident
Penalty
Summary
Facility staff failed to follow a physician's order for daily weight monitoring for one resident diagnosed with congestive heart failure (CHF). The order specified that the resident's weight should be obtained once daily, with instructions to notify the physician or nurse practitioner if the resident gained more than 2.5 pounds in three days or more than 5 pounds in a week. Review of the electronic medication administration record (eMAR) and electronic health record (EHR) revealed missing documentation of the resident's weights on several specified dates. The eMAR indicated 'Other' for these dates, but no explanation was provided in the records or nursing notes. The resident in question was admitted with CHF and was severely cognitively impaired, as indicated by a score of 0 on the Brief Interview for Mental Status (BIMS). Staff interviews confirmed that daily weights were required for CHF monitoring to detect fluid retention, which could impact the resident's heart function. However, the facility was unable to provide evidence that weights were obtained or documented on the specified dates, and staff could not explain the omissions when questioned.
Failure to Obtain Physician-Ordered Daily Weights After Significant Weight Loss
Penalty
Summary
Facility staff failed to monitor a significant weight loss for one resident by not obtaining physician-ordered daily weights after the resident experienced a notable decrease in body weight. The resident's weight dropped from 159 lbs. to 142 lbs. within a month, representing a 10.69% loss. The registered dietician documented concern over a 14% loss in less than a month and requested a reweigh for accuracy, noting the resident was on a regular, pureed diet and receiving tube feeding, which was increased in frequency due to poor oral intake. Despite a physician's order to obtain daily weights, the clinical record showed that weights were not recorded on several specified dates. Staff interviews revealed that daily weights were not obtained due to time management issues among CNAs and uncertainty about the appropriate equipment to use for weighing the resident. The registered dietician emphasized the importance of daily weights for accurate monitoring of the resident's nutritional status. Facility policy required weights to be obtained more frequently if risk was identified or as ordered, but this was not followed in the resident's case.
Deficient Food Storage and Holding Temperatures in Kitchen and Dining Areas
Penalty
Summary
Facility staff failed to store food in a sanitary manner and did not maintain required holding temperatures for food served to residents. During an observation of the kitchen's walk-in refrigerator, an open package of sliced ham and an open bag of shredded cheddar cheese were found without open dates. In the walk-in freezer, two bags of frozen breaded shrimp were found, one of which was open to the environment and the other resealed but not dated. The facility's policy requires all refrigerated and frozen foods to be appropriately dated to ensure proper rotation and to prevent contamination, but this was not followed. Additionally, during lunch service, holding temperatures of several food items on the steam table were recorded below the required minimum of 135°F. Items such as BBQ pork, pureed BBQ pork, pureed vegetables, mixed vegetables, and hamburger were all measured at 100°F to 120°F. Despite this, the food was not returned to the kitchen for reheating as required by facility policy. Staff interviews confirmed a lack of adherence to proper temperature protocols and food storage procedures.
Failure to Complete and Document Bed and Bed Rail Safety Inspections
Penalty
Summary
Facility staff failed to conduct and document required bed and bed rail safety inspections for four residents who utilized bed rails or positioning/assist bars. The facility's policy required annual inspections and additional checks when bed or mattress configurations changed, with documentation maintained by environmental services or maintenance. However, review of inspection records since the last survey showed that inspections were only completed in January 2023 and February 2024, and not all residents with bed rails had evidence of current inspections. For the four residents involved, observations confirmed the use of bed rails or positioning bars, and interviews with staff revealed that the inspection process was incomplete at the time of the survey. Maintenance staff indicated that inspections were performed annually, but also stated that the 2025 inspections were still in progress and not finished. Review of inspection documentation failed to show completed inspections for the affected residents during the relevant period. The residents affected had significant medical conditions and functional impairments, including severe cognitive impairment, congestive heart failure, diabetes mellitus, cerebrovascular accident with hemiplegia, cellulitis, and muscle weakness. Care plans for these residents included the use of bed rails or positioning bars for assistance with turning, repositioning, and mobility. Despite these needs, the facility did not provide evidence that the required safety inspections for beds and bed rails had been completed and documented for these individuals.
Failure to Provide Dignified Dining Experience
Penalty
Summary
Facility staff failed to provide a dignified dining experience for one resident. During observation, a CNA was seen standing over the resident while feeding them as the resident sat up in bed. In a subsequent interview, another CNA confirmed that staff are expected to sit in a chair when feeding residents, as standing does not provide a dignified experience and residents are more comfortable when staff are seated. The facility's own inservice documentation on resident rights emphasizes the right to be treated with dignity. No additional information was provided prior to the survey exit.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
Facility staff failed to provide written notice to a resident prior to two separate room changes, as required by facility policy. The resident reported having recently moved rooms and expressed dissatisfaction with the new room. Review of the clinical record confirmed that the resident was transferred to different rooms on two occasions, but there was no evidence of written notification being provided before either move. Interviews with staff revealed that the social services assistant was responsible for notifying residents of room changes, but acknowledged that the facility's policy did not require written notice. The facility's own policy stated that residents or their representatives should be notified prior to a room or roommate change, with documentation of the notification and the reason for the change. No documentation of written notice was found in the resident's record.
Failure to Notify and Document Reason for Resident Room Change
Penalty
Summary
Facility staff failed to provide a resident with the reason for a room change and did not document the notification or rationale for the transfer. The resident, who had recently been moved to a new room, reported dissatisfaction with her current room and was unaware of the reason for the move. Review of the clinical record confirmed the room transfer but showed no evidence that the resident was informed of the reason. Staff interviews revealed that the move was due to a conflict with a roommate, but this was not documented in the resident's record. Facility policy requires that residents be notified of room or roommate changes, including the reason, and that this notification be documented, but this was not followed in this instance.
Failure to Notify Physician of Resident's Refusal of Lab Testing
Penalty
Summary
Facility staff failed to notify the physician when a resident, who was severely cognitively impaired according to a BIMS score of three, refused ordered laboratory testing on two consecutive days. Physician orders were in place for a basic metabolic profile (BMP) and complete blood count (CBC) to be performed overnight on both dates, and the responsible party had been made aware of the new orders. However, there was no documentation in the resident's progress notes indicating that the labs were obtained, that the resident refused the labs, or that the physician was notified of the refusal. Laboratory patient log sheets confirmed that the resident refused the lab testing on both occasions, but these logs did not show any evidence that the physician was informed of the refusals. Staff interviews revealed that the expected protocol was for the nurse to notify the physician and responsible party and document the refusal in the progress notes when a resident declined lab work. Despite this, there was no documentation to support that these notifications occurred for the resident in question.
Inaccurate MDS Assessment Coding for Restraint Use
Penalty
Summary
Facility staff failed to maintain an accurate Minimum Data Set (MDS) assessment for one resident. The quarterly MDS assessment for this resident was incorrectly coded to indicate the use of a chair that prevents rising, which is considered a restraint, during the 7-day look-back period. However, a review of the resident's clinical record did not show any documentation supporting the use of such a restraint, and direct observation of the resident during the survey also did not reveal the use of a restraint or chair that prevents rising. The MDS coordinator acknowledged that the coding was a data entry error.
Failure to Implement Comprehensive Care Plans for Weight Monitoring and Oxygen Administration
Penalty
Summary
Facility staff failed to implement comprehensive care plans for three residents, resulting in deficiencies related to weight monitoring and oxygen administration. For one resident requiring enteral tube feeding and at risk for dehydration and aspiration, the care plan and physician's order required daily weight monitoring. However, clinical records showed that weights were not obtained on multiple specified dates. Staff interviews revealed that daily weights were missed due to time management issues and uncertainty about the appropriate equipment to use for weighing the resident. Another resident with a physician's order for continuous oxygen at four liters per minute for respiratory failure was observed receiving oxygen at a lower rate, between two and a half and three liters per minute, on two separate occasions. The care plan specified oxygen and nebulizer treatments as ordered, but staff did not administer oxygen at the prescribed rate. Nursing staff confirmed that oxygen should be administered per the physician's order and acknowledged the discrepancy in the observed flow rate. A third resident, who was cognitively intact and required continuous oxygen therapy for COPD and respiratory failure, was observed with their oxygen concentrator set at 3.5 liters per minute instead of the ordered four liters per minute. The care plan directed staff to administer oxygen as ordered, and physician instructions included checking the concentrator and oxygen saturation every shift. Staff interviews confirmed the oxygen was not set at the prescribed rate, and the resident was unaware of the correct flow rate. In all cases, the facility's policy required direct care staff to know and follow each resident's care plan, but this was not consistently done.
Failure to Update Care Plans for Adaptive Equipment and Weight Loss
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for two residents, resulting in deficiencies related to adaptive eating equipment, orthotic devices, and significant weight loss. For one resident, the care plan did not include physician-ordered adaptive eating equipment such as a two-handled cup with a lid and straw, or red foam handles for utensils, despite clinical documentation and staff interviews confirming the resident's need due to hand tremors and ulnar drift. Observations showed the resident was not provided with the required adaptive equipment during meals, and staff were unaware of these needs. Additionally, the care plan did not address a significant, undesired weight loss, even though the dietician had documented the issue and recommended close monitoring and adaptive equipment to assist with eating. Another resident with a visible right-hand contracture was observed feeding herself with her fingers and without adaptive eating equipment, despite occupational therapy recommendations and physician orders for a right-hand carrot orthosis and lightweight utensils. The care plan for this resident did not include these devices, and the resident reported not being offered the orthosis or adaptive utensils, having lost them and not using them regularly. Staff interviews confirmed the recommendations and orders for these devices, but the care plan had not been updated to reflect these needs. Facility policy requires that comprehensive care plans be reviewed and updated at least every 90 days by the interdisciplinary team. However, in both cases, the care plans were not revised to include essential adaptive equipment and interventions as ordered by physicians and recommended by therapy staff, leading to a lack of implementation and awareness among direct care staff.
Failure to Clarify Physician Order for Tracheostomy Tube Change
Penalty
Summary
Facility staff failed to clarify a physician order regarding the scheduled change of a tracheostomy tube for one resident. The resident, who was cognitively intact and had a long-standing tracheostomy, reported performing their own tracheostomy care, with staff providing necessary supplies. Nursing staff offered to assist, but the resident preferred self-care. The physician order specified that the tracheostomy tube should be changed every two months and as needed, with documentation in the electronic medication administration record indicating a tube change was performed. However, there was no documentation in the progress notes regarding the actual procedure. During interviews, the LPN who signed off on the tube change was unsure who performed the change and believed it might have been done by an RN. The LPN admitted to not having changed the tube herself and expressed uncertainty about the specifics of the order, indicating a need to clarify with the nurse practitioner. The facility's policy on physician/provider orders did not provide guidance on clarifying such orders, and there was no evidence that the order had been clarified or that the procedure was properly documented.
Failure to Provide Foot Care for Resident with Diabetes and Impaired Mobility
Penalty
Summary
Facility staff failed to provide appropriate foot care for one resident, as evidenced by observations of the resident in bed with thick toenails on both large toes and toenails approximately one-half inch in length. The resident, who was admitted with diagnoses including congestive heart failure, diabetes mellitus, and osteoarthritis, was assessed as severely cognitively impaired and required maximum assistance with activities of daily living. The care plan indicated a need for assistance with ADLs due to multiple health conditions, and a physician's order was in place for a podiatry consult as needed. Despite these documented needs, there was no evidence that foot care had been provided. The resident reported that toenail care was not performed at the facility and that their son had to take them out for nail trimming. The only podiatry visit note available was from over a year prior, and there was no documentation of recent podiatry appointments or nail care in the resident's records. Staff interviews confirmed that nurses do not trim toenails for residents with diabetes or thick nails and that such residents are supposed to be placed on a podiatry list, but there was no documentation that this had occurred for the resident in question.
Failure to Provide Prescribed Orthotic Device for Contracture Management
Penalty
Summary
Facility staff failed to implement necessary interventions to prevent the worsening of a right-hand contracture for a resident with limited range of motion. The resident was observed multiple times with a visible contracture of the right hand, and although a carrot orthotic device was prescribed and present in the resident's room, it was not consistently provided to the resident. The resident reported that staff did not usually offer the orthotic device, despite being willing to use it to help with her contracture and skin integrity. Clinical records confirmed an active order for daily use of the right-hand carrot orthosis, as tolerated, to prevent skin breakdown and further contractures. Further review revealed that the resident's comprehensive care plan did not include information regarding the need for the right-hand orthotic device, despite occupational therapy's recommendation and discharge summary specifying its use. Interviews with staff indicated awareness of the device and its intended purpose, but observations and resident statements demonstrated a lack of consistent implementation. Facility policy required dissemination of adaptive equipment instructions and coordination among care team members, but this was not reflected in the resident's care plan or daily care practices.
Failure to Administer Oxygen at Prescribed Rates for Two Residents
Penalty
Summary
Facility staff failed to provide respiratory care and services consistent with professional standards of practice for two residents who required continuous oxygen therapy. For one resident with chronic obstructive pulmonary disease and a physician's order for continuous oxygen at 4 liters per minute (lpm), observations revealed the oxygen concentrator was set at 3.5 lpm instead of the prescribed rate. The resident reported using 3 lpm, and the LPN confirmed the concentrator was not set to the ordered rate. The care plan and facility policy both required adherence to the prescribed oxygen flow rate, and the manufacturer's manual specified proper adjustment of the flowmeter. For another resident with a physician's order for continuous oxygen at 4 lpm due to respiratory failure, observations on two occasions showed the oxygen concentrator was set between 2.5 and 3 lpm. The RN interviewed confirmed that oxygen should be administered at the rate specified in the physician's order, with the flowmeter ball aligned with the 4-liter line. These findings indicate that staff did not administer oxygen at the prescribed rates for both residents, as required by physician orders and facility policy.
Failure to Provide Prescribed Adaptive Eating Equipment and Utensils
Penalty
Summary
Facility staff failed to provide physician-prescribed adaptive eating equipment and utensils to two residents with documented needs for such devices. One resident, who was cognitively intact but had a physician's order for a two-handled cup with lid and straw, as well as red foam handles for utensils due to hand tremors and ulnar drift, was observed without the required adaptive equipment during multiple meals. The resident reported that her special cup and foam handles had gone missing, and staff interviews revealed a lack of awareness regarding the resident's need for adaptive equipment, despite clear documentation in the clinical record and meal tray tickets. Another resident, who had occupational therapy recommendations and physician orders for lightweight and built-up utensils to assist with self-feeding, was repeatedly observed attempting to use regular utensils and ultimately resorting to finger feeding. The resident acknowledged losing the adaptive utensils and stated that staff had not provided replacements. Staff interviews indicated a lack of knowledge about the resident's need for specialized eating equipment, and the resident's care plan did not include information about adaptive devices, despite therapy recommendations and orders. Facility policy required provision of adaptive devices per order, but this was not followed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 211 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mechanicsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Covenant Woods Nursing Home | 0.6 mi | ★★★★★ | 0 | 0 |
| Hanover Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 5 | 1 |
| Westminster-canterbury Of Richmond | 6.2 mi | ★★★★★ | 0 | 0 |
| Henrico Health & Rehabilitation Center | 6.3 mi | — | 15 | 0 |
| Lakeside Health & Rehabilitation | 6.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.