Autumn View Assisted Living #1

Facility Information

License Number: FCL-011-363
Site Address: 230 Country Time Circle
Leicester, NC 28728
Capacity: 6 Beds

Statement of Deficiencies

Statements of Deficiencies (form used by the state to document inspections) are posted for adult care facilities with survey dates beginning November 1, 2014 and deficiencies or violations were identified.

Note:  A Yes under the column, IDR Pending, indicates the facility has requested Informal Dispute Resolution (IDR), a process that gives a facility the opportunity to dispute all or some of the findings of a state inspection. If the Statement of Deficiency is changed as a result of IDR, the web page will be updated.

Inspection TypeDocument TypeInspection DatePagesIDR Pending
ACLS Annual No Deficiencies Cited 3/28/2017 No
ACLS Follow-up Statement of Deficiency 10/1/2015 No
Constr Biennial Follow-up No Deficiencies Cited 8/20/2015 0 No
Constr Biennial Follow-up Statement of Deficiency 5/22/2015 2 No
Constr Biennial Statement of Deficiency with Plan of Correction 11/6/2014 4 No
Constr Biennial Statement of Deficiency 11/6/2014 3 No

Star Rating

Star Ratings are based on the results of DHSR inspections and some inspections by the County Department of Social Services (DSS).

StarsScoreIssue DateMeritsDemeritsInspection Type 
Three Stars (3) 95 4/6/2017 5 0 Annual View Worksheet
Three Stars (3) 91 4/6/2017 2.5 0 County Monitoring Visit View Worksheet
Two Stars (2) 88.5 7/12/2016 0 10 County Monitoring Visit View Worksheet
Three Stars (3) 98.5 11/6/2015 2.5 4 Annual View Worksheet
Three Stars (3) 98 10/8/2014 0 2 Annual View Worksheet
Three Stars (3) 92 10/17/2013 0 8 Annual View Worksheet
Three Stars (3) 97 10/5/2012 2.5 0 Follow-up View Worksheet
Three Stars (3) 94.5 7/11/2012 0 5.5 Annual View Worksheet
Three Stars (3) 96 6/22/2011 0 4 Annual View Worksheet
One Star (1) 70.5 2/26/2010 2.5 12 Annual View Worksheet
(ZERO STARS) (0) 68.75 4/13/2009 5 0 Reissue View Worksheet
(ZERO STARS) (0) 63.75 4/7/2009 13.75 0 Follow-up View Worksheet
(ZERO STARS) (0) 50 3/6/2009 0 50 Annual View Worksheet


Penalties imposed during the last 36 months are listed.

Penalty Issued DatePenalty AmountPenalty TypeReason for IssuanceCurrent StatusAmount PaidDate of Payment
Rule CitedNature of Violation
8/10/2017 $6,000.00 Type A1 10A NCAC 13G .1004(a) Medication Administration; G.S. 131D-21(2) Declaration of Residents' Rights Faciity failed to assure that the preparation and administration o medications and treatments by staff were in accordance with physician orders as maintained in the resident's record and rules in thei Section and the facility's policies and procedures resulting in one resident taking another residen's medications and having to be hospitalized.