Inspection Report Summary
The most recent inspection on September 16, 2024, found no deficiencies and confirmed that all previous issues were corrected. Earlier inspections showed some deficiencies related mainly to documentation of incidents, failure to report an allegation of abuse promptly, and emergency preparedness training. Prior reports also noted issues with medication regimen reviews, infection control during the COVID-19 pandemic, and coordination of health care services. Complaint investigations were mostly unsubstantiated, except for one substantiated case involving failure to report an abuse allegation and incomplete resident documentation. The facility appears to have addressed prior deficiencies, showing improvement in recent inspections.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
13 residents
Based on a August 2024 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 16, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-08-28.
Findings
All deficiencies have been corrected as of the compliance date of 2024-09-12, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 3
Date: Aug 28, 2024
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations numbered 190238 and 190131 conducted on 08/27/24 and 08/28/24.
Complaint Details
The complaint involved an allegation that Certified Medication Aide C was observed grabbing Resident 1 aggressively, resulting in bruising. The facility failed to report this allegation to the department within 24 hours as required.
Findings
The facility failed to report an allegation of abuse involving Resident 1 and a Certified Medication Aide within 24 hours, and failed to document incidents of unexplained bruising in the resident's record. Additionally, the facility did not ensure quarterly emergency preparedness training documentation for all residents.
Deficiencies (3)
Failure to report an allegation of abuse involving Resident 1 and Certified Medication Aide C to the department within 24 hours.
Failure to ensure resident record contained documentation of all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results when Resident 1 developed unexplained bruising.
Failure to ensure disaster and emergency preparedness including quarterly review of emergency management plan with employees and residents and documentation of emergency preparedness training.
Report Facts
Census: 13
Residents in sample: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Confirmed failure to report abuse allegation to the department and confirmed emergency preparedness training documentation issues. | |
| Certified Medication Aide C | Certified Medication Aide | Named as alleged perpetrator in abuse allegation involving Resident 1. |
| Certified Nurse Aide D | Certified Nurse Aide | Reported alleged abuse to Licensed Nurse B. |
| Licensed Nurse B | Licensed Nurse | Received abuse allegation report from Certified Nurse Aide D and reported it to Operator A. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 27, 2024
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey with attached complaint investigations numbered 190238 and 190131 conducted on August 27 and 28, 2024.
Complaint Details
The plan of correction is related to complaints numbered 190238 and 190131 attached to the licensure resurvey.
Findings
The plan of correction addresses citations resulting from the licensure resurvey and complaint investigations conducted on the specified dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 21, 2023
Visit Reason
The abbreviated survey was conducted on 11/21/23 in response to complaints #184133 at the assisted living facility.
Complaint Details
Complaint #184133 was investigated and resulted in no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 21, 2023
Visit Reason
The abbreviated survey was conducted on 11/21/23 at the assisted living facility in response to complaints #184133.
Complaint Details
Complaint #184133 was investigated and found to have no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 26, 2023
Visit Reason
The document represents the findings of a complaint investigation conducted at the Residential Healthcare Facility on 06/26/23 and 06/27/23.
Complaint Details
Complaint investigation 180848 was conducted and resulted in no citations.
Findings
The complaint investigation resulted in no citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 26, 2023
Visit Reason
The inspection was conducted as a complaint investigation (complaint number 180848) at the Residential Healthcare Facility named The Autumn Place.
Complaint Details
Complaint investigation number 180848 was conducted and found no citations.
Findings
The complaint investigation conducted on 06/26/23 and 06/27/23 resulted in no citations or deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 9
Date: Mar 9, 2023
Visit Reason
This report documents a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to confirm the dates when corrective actions were completed.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with no uncorrected deficiencies noted.
Deficiencies (9)
Deficiency related to regulation 26-39-102 (a)
Deficiency related to regulation 26-41-201 (a) (b)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-202 (d)
Deficiency related to regulation 26-41-202 (h)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-105 (a)
Deficiency related to regulation 26-41-105 (f) (11)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Report Facts
Deficiencies corrected: 9
Inspection Report
Renewal
Census: 21
Deficiencies: 9
Date: Feb 14, 2023
Visit Reason
The inspection was a licensure resurvey conducted on 02/13/23 and 02/14/23 to assess compliance with state regulations for the assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to have proper written admission agreements, incomplete functional capacity screenings, lack of negotiated service agreements, failure to review service agreements annually, missing signatures on agreements, inadequate health care service coordination, poor maintenance of resident records, incomplete documentation of incidents, and noncompliance with tuberculosis screening requirements.
Deficiencies (9)
Failure to have documentation showing in writing the rates and charges for facility services and resident's obligation regarding payment, and failure to execute a written agreement detailing services and obligations.
Failure to ensure a Functional Capacity Screening was performed prior to or at the time of admission to determine resident's functional capacity.
Failure to ensure a Negotiated Service Agreement was developed based on the Functional Capacity Screen providing a description of services, provider identification, and payment responsibility.
Failure to review and revise the Negotiated Service Agreement at least once every 365 days for a resident.
Failure to ensure each individual involved in the development of the Negotiated Service Agreement signed the agreement.
Failure to ensure a licensed nurse provided or coordinated necessary health care services in accordance with the Functional Capacity Screen and Negotiated Service Agreement.
Failure to maintain resident records in accordance with accepted professional standards, with loose and unsecured documents and incomplete records.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results for residents.
Failure to ensure compliance with tuberculosis guidelines, including lack of documentation of required first and second step TB skin tests within required timeframes.
Report Facts
Census: 21
Deficiency count: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Confirmed deficiencies related to documentation and records | |
| Owner B | Confirmed deficiencies related to documentation and records |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 13, 2023
Visit Reason
The document is a plan of correction submitted in response to findings from the licensure resurvey conducted on 02/13/23 and 02/14/23 at the facility.
Findings
The plan of correction addresses citations identified during the licensure resurvey conducted on 02/13/23 and 02/14/23. Specific deficiencies are not detailed in this document.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 5, 2021
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey, verifying that corrective actions were completed as of the revisit date.
Findings
The report confirms that all previously identified deficiencies related to specific regulations were corrected by the revisit date of January 5, 2021.
Deficiencies (3)
Deficiency related to regulation 26-41-205 (l)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Deficiency related to regulation 26-41-207 (b) (7)
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2021
Visit Reason
An abbreviated survey for complaint investigation 148430 was conducted at the residential healthcare facility.
Complaint Details
Complaint investigation 148430 resulted in no deficiency citations.
Findings
The survey conducted on 01/04/2021 and 01/05/2021 resulted in a finding of no deficiency citations.
Inspection Report
Renewal
Census: 15
Deficiencies: 3
Date: Dec 15, 2020
Visit Reason
The inspection was conducted for re-licensure with attached complaints #149850, #158068, and #135779 on 12/09/2020, 12/10/2020, 12/14/2020, and 12/15/2020 at The Autumn Place assisted living facility in Columbus, KS.
Complaint Details
The visit was triggered by complaints #149850, #158068, and #135779. The findings included substantiated failures related to medication regimen reviews and infection control practices during the COVID-19 pandemic.
Findings
The facility failed to ensure that a licensed pharmacist conducted quarterly medication regimen reviews for residents, and failed to prohibit employees with communicable diseases, including COVID-19, from coming into direct contact with residents, their food, or care equipment. Additionally, the facility did not provide adequate isolation precautions to protect residents who tested negative for COVID-19, resulting in harm.
Deficiencies (3)
Failure to ensure a licensed pharmacist conducted quarterly medication regimen reviews for residents whose medication is managed by the facility.
Failure to prohibit employees with communicable diseases from coming into direct contact with residents, resident's food, or resident care equipment until the condition is no longer infectious.
Failure to provide isolation precautions necessary to protect the health of residents who tested negative for COVID-19.
Report Facts
Census: 15
Residents tested positive for COVID-19: 13
Staff tested positive for COVID-19: 7
Residents tested negative for COVID-19: 2
Sampled residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided interviews regarding medication regimen reviews and COVID-19 infection control practices. | |
| Cherokee County Health Department Registered Nurse (RN) | Provided guidance and instructions related to COVID-19 testing and quarantine measures. |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 20, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/20/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Census: 18
Deficiencies: 3
Date: Aug 29, 2018
Visit Reason
This document reports the findings of a resurvey conducted on 8-27-18, 8-28-18, and 8-29-18 at The Autumn Place, a residential health care facility, to assess compliance with health care service requirements and medication management.
Findings
The facility was found deficient in coordinating necessary health care services for a resident regarding the use of siderails, including lack of safety assessment and instructions. Additionally, medications were administered by certified staff without proper nurse instruction or follow-up assessment. The medication regimen review failed to identify potential or current medication-related problems, including lack of clinical indication for use of multiple medications for three sampled residents.
Deficiencies (3)
Failed to provide or coordinate necessary health care services regarding use of siderails including safety assessment and instructions in the negotiated service agreement.
Failed to ensure all medications and biologicals were administered in accordance with medical orders and professional standards; PRN medications were administered by certified staff without nurse instruction or follow-up assessment.
Failed to ensure medication regimen review identified potential or current medication-related problems including lack of clinical indication for use of medications.
Report Facts
Census: 18
Sample size: 3
Medication administrations: 19
Medication administrations: 5
Medication administrations: 31
Medication administrations: 11
Medication administrations: 27
Medication administrations: 2
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 9, 2016
Visit Reason
The document is a licensure resurvey of a residential health care facility conducted to assess compliance for license renewal.
Findings
The licensure resurvey resulted in no deficiency citations on the inspection dates of August 8 and August 9, 2016.
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 14, 2015
Visit Reason
The inspection was a licensure resurvey conducted at the residential health care facility to assess compliance with licensure requirements.
Findings
The licensure resurvey resulted in a finding of no deficiency citations on 4-14-15.
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