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Deficiency Records for Autumn Leaves
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.
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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-06-13 | 2024-07-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-06-13 | 2024-07-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-06-13 | 2024-07-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-13 | 2024-07-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-13 | 2024-07-05 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2024-06-13 | 2024-07-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-06-13 | 2024-07-01 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-06-13 | 2024-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-12 | 2024-06-13 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-04-17 | 2024-04-02 | Y |
| 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 |
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