Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Life Safety
Deficiencies: 7
Nov 4, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Autumn Haven Assisted Living, Inc.
Findings
The facility failed to provide documentation of smoke detector sensitivity testing within the last five years and did not maintain required inspections and testing of fire suppression systems and components. Additionally, prohibited electrical devices were found in use powering oxygen concentrators in resident rooms.
Deficiencies (7)
| Description |
|---|
| Facility could not provide documentation of testing sensitivity of smoke detectors within the last five years. |
| Facility failed to maintain visual inspection of fire suppression wet pressure gauges monthly as required. |
| Facility failed to maintain semi-annual testing of Vane-type fire suppression systems. |
| Facility failed to maintain components and valves of the fire suppression system, including gauge calibration and internal valve inspections. |
| Facility failed to maintain Post Indicator Valve (PIV) in accordance with NFPA standards; PIV viewing screen was damaged and condition could not be verified. |
| Use of a multi-plug adapter to power an oxygen concentrator in room #15, which is prohibited. |
| Use of a relocatable power tab (RPT) to power an oxygen concentrator in room #12, which is prohibited. |
Report Facts
Facility License Number: RC-1256
Survey Date: 11/04/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angie Darrington | Administrator | Named as facility administrator |
| Jeremy Wilson | Survey Team Leader | Named as survey team leader for fire life safety and sanitation licensure |
Inspection Report
Follow-Up
Deficiencies: 10
Dec 13, 2023
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
The facility was found to have multiple deficiencies including incomplete criminal background checks for staff, inadequate abuse/neglect/exploitation policies, failure to conduct timely investigations, failure to notify licensing agency of incidents, improper hot water temperatures, missing psychotropic medication reviews, outdated negotiated service agreements, failure to notify nursing staff of resident symptoms, and lack of behavior assessments and plans for residents with maladaptive behaviors.
Deficiencies (10)
| Description |
|---|
| The facility did not complete background checks for all employees who had direct resident access. |
| The facility's abuse/neglect/exploitation policy did not include all required elements. |
| The administrator did not conduct an investigation within 30 days for multiple incidents involving Resident #3. |
| The facility did not notify Licensing and Certification within one business day of two residents' falls with injuries. |
| Hot water temperatures were not consistently maintained between 105 and 120 degrees F, with readings at 128 degrees F. |
| Six-month psychotropic medication reviews were not completed for two residents who required them. |
| Four residents did not have updated Negotiated Service Agreements reflecting current needs. |
| Staff did not notify the facility nurse of residents' symptoms including vomiting, diarrhea, headaches, pain, dizziness, and vision changes. |
| The facility did not ensure residents' maladaptive behaviors were assessed. |
| The facility did not develop a behavior plan with specific interventions for Resident #3's behaviors. |
Report Facts
Staff without completed background check: 1
Residents without updated Negotiated Service Agreements: 4
Residents without psychotropic medication reviews: 2
Hot water temperature reading: 128
Resident #3 unsolicited sexual advances: 7
Resident #3 inappropriate contact incidents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angie Darrington | Administrator | Named in relation to failure to conduct investigations and lack of knowledge about reporting requirements |
| Megan Rideout | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Deficiencies: 2
Sep 22, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for Autumn Haven Assisted Living, Inc.
Findings
The facility failed to perform the required bimonthly emergency egress and relocation drills, with only five drills documented over more than a year. Additionally, the natural gas fireplace in the living area lacked an adequate safety barrier, as the screen did not prevent contact with the glass.
Deficiencies (2)
| Description |
|---|
| Failure to perform emergency egress and relocation drills bimonthly as required. |
| Natural gas fireplace screen did not prevent the glass from being touched; no other safety barrier present. |
Report Facts
Number of emergency drills performed: 5
Required minimum emergency drills per year: 6
Inspection Report
Original Licensing
Deficiencies: 4
Jun 30, 2022
Visit Reason
The inspection was conducted as an initial licensure survey following the facility's change of ownership.
Findings
The survey identified deficiencies related to incomplete criminal history and background checks for two of four staff members, and incomplete comprehensive nursing assessments and change of condition assessments for several residents. The facility nurse was not available for interview.
Deficiencies (4)
| Description |
|---|
| Two of four staff members did not have a current criminal history and background check completed after the facility's change of ownership. |
| The facility nurse did not complete comprehensive nursing assessments for Resident #2 and Resident #4. |
| The facility nurse did not complete change of condition assessments when Residents #1, #2, and #4 had pressure injuries or surgical site infections. |
| The facility nurse did not delegate four of four medication technicians prior to assisting residents with medications. |
Report Facts
Staff members with incomplete criminal history checks: 2
Residents with incomplete nursing assessments: 2
Residents with incomplete change of condition assessments: 3
Medication technicians not delegated: 4
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