A list of the most recent deficiencies for Autumn Leaves. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-04 | 2023-05-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-04 | 2023-05-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-04 | 2023-05-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-04 | 2023-05-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-04 | 2023-05-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-04 | 2023-05-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-04 | 2023-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-04 | 2023-05-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-04 | 2023-05-22 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-05-04 | 2023-05-22 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-05-04 | 2023-05-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-04-20 | 2022-05-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-20 | 2022-05-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-20 | 2022-05-31 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-21 | 2022-05-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-21 | 2022-05-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-21 | 2022-05-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-21 | 2022-05-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-04-21 | 2022-05-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-21 | 2022-05-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-18 | 2021-09-17 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-18 | 2021-06-19 | Y |
| Keep all essential equipment working safely. | Health | 2019-10-03 | 2019-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-03 | 2019-11-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-03 | 2019-11-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-10-03 | 2019-11-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-01 | 2019-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-01 | 2019-10-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-01 | 2019-10-21 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-10-01 | 2019-10-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-01 | 2019-10-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-01 | 2019-10-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-01 | 2019-10-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-01 | 2019-10-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-01 | 2019-10-02 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-10-01 | 2019-10-02 | N |
