Autumn Care of Madison: Medication Falsification - VA
The Director of Nursing, interviewed by inspectors on April 23, was direct about what the practice represented. Staff should never mark medications as given when they weren't available, she told inspectors. If a medication was missing, she said, she should be notified so it could be obtained from the pharmacy.
That didn't happen.
The facility's own written policy, last revised in August 2024, spells out the expectation clearly: when staff discover an inadequate supply of a medication at the time of administration, they are to notify the pharmacy immediately. The policy has existed in some form since 2001.
What inspectors found was the opposite. Rather than flagging the shortage and getting the drug, staff marked the medication as given. Residents received a notation in their records suggesting they had gotten a dose they hadn't.
The gap between a falsified medication record and an actual missed dose matters in ways that compound over time. A resident whose chart shows a medication administered has no visible flag that a dose was skipped. Caregivers on the next shift, reviewing that record, have no reason to follow up. Physicians reviewing medication logs see compliance where there wasn't any.
Inspectors classified the harm level as minimal, with few residents affected. Whether any resident experienced a consequence from the missed doses, the inspection report does not say. What it does say is that the people responsible for tracking what medications residents received were recording things that weren't true, and the nurse responsible for overseeing their work didn't know it was happening.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Care of Madison from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
AUTUMN CARE OF MADISON in MADISON, VA was cited for violations during a health inspection on April 24, 2026.
The Director of Nursing, interviewed by inspectors on April 23, was direct about what the practice represented.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.