Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 24, 2021
Visit Reason
The inspection was conducted as a complaint investigation regarding medication administration discrepancies at Autumn Springs Assisted Living.
Findings
The investigation found that Resident #1 received 8 tablets of Resident #2's 5 mg oxycodone, and medication administration records did not match the narcotic log, with discrepancies in oxycodone dosages documented and administered.
Complaint Details
Complaint investigation regarding medication administration errors involving oxycodone dosages and record discrepancies.
Deficiencies (2)
| Description |
|---|
| Resident #1 received 8 tablets of Resident #2's 5 mg oxycodone. |
| Medication Administration Records (MARs) dosage for Resident #1 did not match the Narcotic Log; 5 mg oxycodone tablets were signed out as 10 mg. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margo Ball | Administrator | Named in medication administration discrepancies and interview. |
| Noelle Markland | Survey Team Leader | Led the complaint inspection. |
Inspection Report
Original Licensing
Deficiencies: 2
Jul 18, 2019
Visit Reason
The inspection was conducted as an initial licensing inspection of Autumn Springs Assisted Living facility.
Findings
The inspection identified deficiencies related to employee files, specifically the lack of a current, initialed job description for the administrator and absence of written documentation of findings for screening of another employee.
Deficiencies (2)
| Description |
|---|
| No current, initialed job description for employee #1, Administrator. |
| No evidence of written documentation of findings for screening of employee #2. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margo Ball | Administrator | Named as employee #1 with missing job description. |
| Brett Christian | Survey Team Leader | Led the initial inspection. |
Inspection Report
Complaint Investigation
Capacity: 66
Deficiencies: 2
Sep 18, 2018
Visit Reason
The inspection was conducted as a complaint investigation regarding placement of residents not meeting facility category requirements and staffing issues affecting housekeeping services.
Findings
The facility was found to have residents placed inappropriately without required notice and was experiencing staffing shortages impacting housekeeping and resident care needs.
Complaint Details
Complaint inspection triggered by concerns about resident placement and staffing adequacy. No substantiation status explicitly stated.
Deficiencies (2)
| Description |
|---|
| Residents #1, #2, & #3 do not meet the requirements for Category A but do meet the requirements for Category C; no 30 day notice was given for these residents. |
| Facility is experiencing difficulty in providing adequate housekeeping services due to lack of qualified staff, resulting in rooms not being cleaned and garbage not emptied for about the last month. |
Report Facts
Licensed bed capacity: 66
Number of residents not meeting category requirements: 3
Inspection Report
Renewal
Deficiencies: 3
Sep 19, 2017
Visit Reason
The inspection was conducted as a renewal inspection of Autumn Springs Assisted Living facility to assess compliance with regulatory standards.
Findings
The inspection identified three core issues: unlabeled and undated prepared food in the kitchen refrigerator, lack of protective covers for staff handling soiled laundry, and incomplete documentation of employee orientation in three out of four employee files reviewed.
Deficiencies (3)
| Description |
|---|
| Prepared food (jello salad) in kitchen refrigerator was not labeled and dated. |
| No protective covers for staff to use while working with soiled laundry. |
| Three out of four employee files reviewed did not have initialed documentation of employee orientation. |
Inspection Report
Renewal
Deficiencies: 3
Jun 16, 2016
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with licensing requirements for Autumn Springs Assisted Living.
Findings
The survey identified deficiencies including resident service plans not reflecting activity director's identification of resident needs, the facility not providing therapeutic or special diets despite admission criteria indicating otherwise, and a broken outside window in the meeting room.
Deficiencies (3)
| Description |
|---|
| Resident service plans do not reflect activity director’s identification of resident needs and interests of resident activity information. |
| Facility does not provide therapeutic or special diets as stated in admission criteria, contrary to facility agreement. |
| An outside window (approx. 2.5’ x 4’) in the meeting room of the first floor is broken. |
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