Inspection Reports for Autumn Lane Health and Rehabilitation
302 GEORGIA 18 EAST, GRAY, GA, 31032
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 2, 2025, found no deficiencies after a revisit survey confirmed correction of prior issues. Earlier inspections, particularly the May 16, 2025 survey, identified deficiencies related to infection control during wound care, medication administration errors exceeding the acceptable rate, and inadequate assistance with activities of daily living such as bathing and oral hygiene for residents. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. Complaint investigations over the years were mostly unsubstantiated, with one substantiated complaint in 2019 involving a resident fall due to insufficient staff assistance, which resulted in a written warning for the responsible staff member. The facility appears to have addressed recent deficiencies effectively, as indicated by the clean results in the latest revisit survey.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
82 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Autumn Lane Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Census: 82
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the May 16, 2025, recertification survey.
Findings
All deficiencies cited in the previous recertification survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Deficiencies: 3
Date: May 16, 2025
Visit Reason
A State Licensure survey was conducted from May 12, 2025 through May 16, 2025 at Autumn Lane Health and Rehabilitation to assess compliance with state health regulations.
Findings
The survey identified deficiencies including failure to adhere to infection control practices during wound care, a medication error rate exceeding five percent, and failure to provide adequate assistance with activities of daily living such as bathing and oral hygiene for residents.
Deficiencies (3)
Failure to adhere to infection control practices during wound care, including not performing hand hygiene during glove changes and placing supplies on dirty bedside tables for two residents.
Medication error rate of eight percent due to incorrect dosages administered to two residents out of 25 medication administration opportunities.
Failure to provide staff assistance with activities of daily living, bathing, and oral hygiene for one resident, with lack of documentation of bathing over a nearly one-month period.
Report Facts
Medication error rate: 8
Medication errors: 2
Medication administration opportunities: 25
Resident sample size for wound care observation: 22
Resident sample size for ADL review: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Assistant | Named in medication error findings for administering incorrect dosages to residents R45 and R77. |
| Director of Nursing | Director of Nursing | Provided statements regarding expectations for wound care nurse and medication administration, and confirmed lack of bathing documentation. |
| Wound Care Nurse | Wound Care Nurse | Observed failing to perform hand hygiene during glove changes and placing supplies on dirty bedside tables during wound care. |
| CNA1 | Certified Nurses' Assistant | Provided information about bathing schedules and resident care. |
Inspection Report
Routine
Census: 81
Deficiencies: 3
Date: May 16, 2025
Visit Reason
A standard survey was conducted by Healthcare Management Solutions, LLC, on behalf of the Georgia Department of Community Health, at Autumn Lane Health and Rehabilitation from May 12, 2025, through May 16, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found noncompliant with regulations, including failures to provide adequate assistance with activities of daily living (ADLs) such as bathing and oral hygiene for one resident, medication administration errors resulting in an 8% error rate, and deficient infection control practices during wound care for two residents.
Deficiencies (3)
Failed to provide staff assistance with activities of daily living (ADLs), bathing, and oral hygiene for one resident (R78), negatively impacting quality of life.
Failed to ensure medication error rate below five percent; two medication errors out of 25 opportunities (8% error rate) involving incorrect dosages administered to residents R45 and R77.
Failed to adhere to infection control practices during wound care, including failure to perform hand hygiene during glove changes and placing supplies on dirty bedside tables for residents R81 and R29, increasing risk of cross-contamination and infections.
Report Facts
Medication errors: 2
Resident census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Assistant | Named in medication error findings for administering incorrect dosages to residents R45 and R77. |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding bathing schedules, medication administration expectations, and wound care protocols. |
| Wound Care Nurse | Wound Care Nurse (WCN) | Observed during wound care deficiencies related to hand hygiene and infection control. |
| CNA1 | Certified Nurses' Assistant | Interviewed regarding bathing schedules and resident R78's care. |
Inspection Report
Routine
Deficiencies: 3
Date: May 16, 2025
Visit Reason
A State Licensure survey was conducted at Autumn Lane Health and Rehabilitation from May 12, 2025, through May 16, 2025, to assess compliance with state health regulations.
Findings
The survey identified deficiencies in infection control practices during wound care, medication administration errors exceeding the acceptable rate, and failure to provide adequate assistance with activities of daily living including bathing and oral hygiene for residents.
Deficiencies (3)
Failure to adhere to infection control practices during wound care, including inadequate hand hygiene and placing supplies on unclean surfaces for two residents.
Medication errors occurred with two residents where the correct dosage was not administered, resulting in an 8% medication error rate.
Failure to provide staff assistance with activities of daily living, bathing, and oral hygiene for one resident, with lack of documentation of baths over a nearly one-month period.
Report Facts
Medication error rate: 8
Medication errors: 2
Medication administration opportunities: 25
Resident sample size for wound care observation: 22
Resident sample size for ADL review: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Assistant | Named in medication administration errors involving residents R45 and R77. |
| Director of Nursing | Director of Nursing | Provided statements regarding expectations for wound care nurse and medication administration, and confirmed bathing documentation deficiencies. |
| Wound Care Nurse | Wound Care Nurse | Observed failing to perform hand hygiene during wound care for residents R81 and R29. |
| CNA1 | Certified Nursing Assistant | Provided information about bathing schedules and documentation. |
Inspection Report
Routine
Census: 81
Deficiencies: 3
Date: May 16, 2025
Visit Reason
A standard survey was conducted by Healthcare Management Solutions, LLC, on behalf of the Georgia Department of Community Health, at Autumn Lane Health and Rehabilitation from May 12, 2025, through May 16, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found noncompliant with regulations, including failure to provide adequate assistance with activities of daily living (ADLs) such as bathing and oral hygiene for one resident, medication administration errors resulting in an 8% error rate, and failure to adhere to infection control practices during wound care, increasing risk of cross-contamination and infection.
Deficiencies (3)
Failure to provide staff assistance with activities of daily living (ADLs), bathing, and oral hygiene for one resident.
Failed to ensure a medication error rate below five percent; two medication errors out of 25 opportunities (8% error rate).
Failed to adhere to infection control practices during wound care, including failure to perform hand hygiene during glove changes and placing supplies on dirty bedside tables for two residents.
Report Facts
Medication errors: 2
Resident census: 81
BIMS score: 15
BIMS score: 8
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Assistant | Named in medication error findings for administering incorrect dosages to residents R45 and R77. |
| CNA1 | Certified Nurses' Assistant | Interviewed regarding bathing schedules and documentation related to resident R78. |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding bathing schedules, medication administration expectations, and wound care procedures. |
| Wound Care Nurse | Wound Care Nurse (WCN) | Observed during wound care procedures with noted infection control deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 16, 2025
Visit Reason
A State Licensure survey was conducted from May 12, 2025 through May 16, 2025 at Autumn Lane Health and Rehabilitation to assess compliance with state health regulations.
Findings
The survey identified deficiencies including failure to adhere to infection control practices during wound care, a medication error rate exceeding five percent, and failure to provide adequate assistance with activities of daily living such as bathing and oral hygiene for residents.
Deficiencies (3)
Failure to perform hand hygiene during glove changes and placing supplies on a resident's dirty bedside table during wound care for two residents, increasing risk of cross-contamination and infections.
Medication errors occurred for two residents where the correct dosage was not administered, resulting in an 8% medication error rate.
Failure to provide staff assistance with activities of daily living, bathing, and oral hygiene for one resident, negatively impacting quality of life.
Report Facts
Medication error rate: 8
Medication errors: 2
Medication administration opportunities: 25
Residents reviewed for wound care: 22
Residents reviewed for ADLs: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Assistant | Named in medication error findings for incorrect medication administration. |
| Director of Nursing | Director of Nursing | Provided statements regarding expectations for wound care nurse and medication administration. |
| Wound Care Nurse | Wound Care Nurse | Observed failing to perform hand hygiene during wound care. |
| CNA1 | Certified Nurses' Assistant | Provided information about bathing schedules and resident care. |
Inspection Report
Routine
Census: 81
Deficiencies: 3
Date: May 16, 2025
Visit Reason
A standard survey was conducted by Healthcare Management Solutions, LLC, on behalf of the Georgia Department of Community Health at Autumn Lane Health and Rehabilitation from May 12, 2025, through May 16, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found noncompliant with regulations, including failures to provide adequate assistance with activities of daily living (ADLs) such as bathing and oral hygiene for one resident, medication administration errors resulting in an 8% error rate, and deficient infection control practices during wound care for two residents.
Deficiencies (3)
Failure to provide staff assistance with activities of daily living (ADLs), bathing, and oral hygiene for one resident.
Failed to ensure a medication error rate below five percent; two medication errors out of 25 opportunities (8% error rate).
Failed to adhere to infection control practices during wound care, including failure to perform hand hygiene during glove changes and placing supplies on dirty bedside tables for two residents.
Report Facts
Census: 81
Medication error rate: 8
Medication errors: 2
Medication administration opportunities: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Assistant | Named in medication error findings for administering incorrect dosages to residents R45 and R77. |
| CNA1 | Certified Nurses' Assistant | Interviewed regarding bathing schedules and documentation related to resident R78. |
| Director of Nursing | Director of Nursing (DON) | Provided statements confirming deficiencies in bathing documentation, medication administration expectations, and wound care procedures. |
| Wound Care Nurse | Wound Care Nurse (WCN) | Observed and interviewed regarding deficient infection control practices during wound care for residents R81 and R29. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 16, 2025
Visit Reason
A State Licensure survey was conducted at Autumn Lane Health and Rehabilitation from May 12, 2025, through May 16, 2025, to assess compliance with state health regulations.
Findings
The survey identified deficiencies including failure to adhere to infection control practices during wound care, a medication error rate exceeding five percent, and failure to provide adequate assistance with activities of daily living such as bathing and oral hygiene for residents.
Deficiencies (3)
Failure to adhere to infection control practices during wound care, including not performing hand hygiene during glove changes and placing supplies on dirty bedside tables for two residents.
Medication error rate of eight percent due to incorrect dosages administered to two residents out of 25 opportunities.
Failure to provide staff assistance with activities of daily living, bathing, and oral hygiene for one resident, with documentation showing missed baths over several weeks.
Report Facts
Medication error rate: 8
Medication errors: 2
Medication administration opportunities: 25
Resident sample size for wound care observation: 22
Residents reviewed for ADLs: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Assistant | Named in medication error findings for administering incorrect dosages. |
| Director of Nursing | Director of Nursing | Provided statements regarding expectations for wound care nurse and medication administration. |
| Wound Care Nurse | Wound Care Nurse | Observed failing to perform hand hygiene during wound care. |
| CNA1 | Certified Nurses' Assistant | Provided information about bathing schedules and resident care. |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 3
Date: May 16, 2025
Visit Reason
A standard survey was conducted by Healthcare Management Solutions, LLC, on behalf of the Georgia Department of Community Health, at Autumn Lane Health and Rehabilitation from May 12, 2025, through May 16, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found noncompliant with regulations, with deficiencies including failure to provide adequate assistance with activities of daily living (bathing and oral hygiene) for one resident, medication administration errors resulting in an 8% error rate, and failure to adhere to infection control practices during wound care, increasing risk of cross-contamination and infections.
Deficiencies (3)
Failure to provide staff assistance with activities of daily living (ADLs), bathing, and oral hygiene for one resident (R78).
Medication errors for two residents (R45 and R77) where the correct dosage was not administered, resulting in an 8% medication error rate.
Failure to adhere to infection control practices during wound care, including not performing hand hygiene during glove changes and placing supplies on dirty bedside tables for two residents (R81 and R29).
Report Facts
Medication error rate: 8
Residents reviewed for ADLs: 18
Residents observed for wound care: 22
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Assistant | Named in medication error findings for incorrect dosage administration |
| CNA1 | Certified Nurses' Assistant | Interviewed regarding bathing schedule and resident R78 care |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding bathing documentation, medication administration expectations, and wound care procedures |
| Wound Care Nurse | Wound Care Nurse (WCN) | Observed and interviewed regarding wound care practices and infection control |
Inspection Report
Routine
Deficiencies: 3
Date: May 16, 2025
Visit Reason
A State Licensure survey was conducted by Healthcare Management Solutions, LLC, on behalf of the Georgia Department of Community Health, at Autumn Lane Health and Rehabilitation from May 12, 2025, through May 16, 2025, to assess compliance with state health regulations.
Findings
The survey identified multiple deficiencies including failure to adhere to infection control practices during wound care, a medication error rate exceeding five percent, and failure to provide adequate staff assistance with activities of daily living such as bathing and oral hygiene for residents.
Deficiencies (3)
Failure to adhere to infection control practices during wound care, including not performing hand hygiene during glove changes and placing supplies on dirty bedside tables for two residents.
Medication error rate of eight percent due to incorrect dosages administered to two residents out of 25 medication administration opportunities.
Failure to provide staff assistance with activities of daily living, bathing, and oral hygiene for one resident, with lack of documentation of baths over a nearly one-month period.
Report Facts
Medication error rate: 8
Medication errors: 2
Medication administration opportunities: 25
Resident sample size for wound care observation: 22
Bathing documentation gap: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Assistant | Named in medication error findings for incorrect medication administration. |
| Director of Nursing | Director of Nursing | Provided statements regarding expectations for wound care nurse and medication administration. |
| Wound Care Nurse | Wound Care Nurse | Observed failing to perform hand hygiene during wound care procedures. |
| CNA1 | Certified Nursing Assistant | Provided information about bathing schedules and resident care. |
Inspection Report
Routine
Census: 81
Deficiencies: 3
Date: May 16, 2025
Visit Reason
A standard survey was conducted by Healthcare Management Solutions, LLC, on behalf of the Georgia Department of Community Health at Autumn Lane Health and Rehabilitation from May 12, 2025, through May 16, 2025, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found noncompliant with regulations, including failure to provide adequate assistance with activities of daily living (ADLs) such as bathing and oral hygiene for one resident, medication administration errors resulting in an 8% error rate, and failure to adhere to infection control practices during wound care, increasing risk of cross-contamination.
Deficiencies (3)
Failure to provide staff assistance with activities of daily living (ADLs), bathing, and oral hygiene for one resident.
Failed to ensure a medication error rate below five percent; two medication errors out of 25 opportunities (8% error rate).
Failed to adhere to infection control practices during wound care, including failure to perform hand hygiene during glove changes and placing supplies on dirty bedside tables for two residents.
Report Facts
Medication error rate: 8
Residents reviewed for ADLs: 18
Residents observed for wound care: 22
Facility census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Assistant | Named in medication error findings for administering incorrect dosages to residents R45 and R77. |
| CNA1 | Certified Nurses' Assistant | Interviewed regarding bathing schedules and care for resident R78. |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding bathing documentation, medication administration expectations, and wound care procedures. |
| Wound Care Nurse | Wound Care Nurse (WCN) | Observed and interviewed regarding wound care practices and infection control deficiencies. |
Inspection Report
Life Safety
Census: 82
Capacity: 85
Deficiencies: 0
Date: May 15, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and emergency preparedness requirements at Autumn Lane Health and Rehabilitation.
Findings
The facility was found to be in substantial compliance with the requirements set forth in 42 CFR § 483.73 and 42 CFR Subpart 483.90(a), as well as the NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Abbreviated Survey
Census: 83
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00245015 and GA00250423.
Complaint Details
Complaints GA00245015 and GA00250423 were investigated and found to be unsubstantiated.
Findings
The complaints GA00245015 and GA00250423 were unsubstantiated, and no regulatory violations were cited during the survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
A Life Safety Code revisit was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the Life Safety Code revisit.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Autumn Lane Health and Rehabilitation, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings within the provided page.
Inspection Report
Follow-Up
Census: 85
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the September 24, 2023 Recertification survey.
Findings
All deficiencies cited in the previous Recertification survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Census: 85
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00241076.
Complaint Details
Complaint GA00241076 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint GA00241076 was unsubstantiated with no deficiencies found during the survey.
Inspection Report
Life Safety
Census: 85
Capacity: 85
Deficiencies: 2
Date: Nov 14, 2023
Visit Reason
An unannounced Emergency Preparedness survey and a Life Safety Code Federal Monitoring Survey were conducted following a state agency survey. The visit was to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in substantial compliance with emergency preparedness requirements but was not in substantial compliance with life safety code requirements. Deficiencies included failure to install automatic sprinklers in one room (Entrance Lobby Closet) and failure to maintain the smoke and half-hour fire resistance of smoke barriers, including penetrations by wiring that were not properly fire stopped.
Deficiencies (2)
Failure to install automatic sprinklers in the Entrance Lobby Closet.
Failure to maintain the smoke and half-hour fire resistance of the smoke barriers; penetrations by wiring not completely fire stopped in the Daylily Hall smoke barrier.
Report Facts
Census: 85
Total Capacity: 85
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present during identification of sprinkler and smoke barrier deficiencies | |
| Administrator | Present during identification of sprinkler and smoke barrier deficiencies |
Inspection Report
Routine
Census: 81
Deficiencies: 5
Date: Sep 24, 2023
Visit Reason
A standard survey was conducted at Autumn Lane Health and Rehabilitation from 9/22/2023 to 9/24/2023 to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found noncompliant with several regulations including inaccurate Minimum Data Set (MDS) assessments for three residents, failure to update care plans, failure to report significant weight loss, improper labeling and dating of opened food items, and inadequate infection control during catheter care.
Deficiencies (5)
Failed to ensure accurate Minimum Data Set assessments for three of 25 sampled residents.
Failed to update care plan for one of 25 residents following MDS assessment.
Failed to report significant weight loss for one of four residents reviewed for nutrition.
Failed to ensure opened food items were labeled and dated appropriately.
Failed to implement effective infection control by not ensuring CNA washed/sanitized hands during catheter care for one resident.
Report Facts
Resident census: 81
Residents receiving oral diet: 79
Weight loss percentage: 5.97
Weight loss percentage: 7.35
Weight loss percentage: 10
Weight loss percentage: 6.35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in infection control deficiency for catheter care |
| Director of Nursing | Director of Nursing | Confirmed MDS assessment inaccuracies and commented on staff training and expectations |
| Dietary Manager | Dietary Manager | Acknowledged failure to label/dating food items and failure to report weight loss |
| Assistant Dietary Manager | Assistant Dietary Manager | Responsible for weighing residents and notifying DON of weight changes |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessment inaccuracies |
Inspection Report
Routine
Census: 81
Deficiencies: 3
Date: Sep 24, 2023
Visit Reason
A State Licensure survey was conducted at Autumn Lane Health and Rehabilitation from September 22, 2023 through September 24, 2023 to assess compliance with state health regulations.
Findings
The survey identified deficiencies including failure to report significant weight loss for a resident, ineffective infection control practices during catheter care, and failure to label and date opened food items in the facility.
Deficiencies (3)
Failure to ensure significant weight loss was reported for one resident (R50).
Failure to implement effective infection control by not ensuring CNA washed/sanitized hands during catheter care for one resident (R36).
Failure to ensure opened food items were labeled and dated.
Report Facts
Facility census: 81
Residents receiving oral diet: 79
Weight loss percentage: 5.97
Weight loss percentage: 7.35
Weight loss percentage: 10
Weight loss percentage: 6.35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Completed nutritional assessment and acknowledged weight loss reporting failure |
| Assistant Dietary Manager | Assistant Dietary Manager | Responsible for weighing residents and notifying DON |
| Director of Nursing | Director of Nursing | Oversaw weight audit and commented on infection control and catheter care training |
| CNA AA | Certified Nursing Assistant | Observed failing to wash hands during catheter care |
Inspection Report
Life Safety
Census: 83
Capacity: 85
Deficiencies: 1
Date: Sep 23, 2023
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.70(a) and the NFPA 101 Life Safety Code 2012 Edition requirements for participation in Medicare/Medicaid.
Findings
The facility was not found in substantial compliance due to failure to ensure hazardous areas were properly enclosed and compartmentalized. Specifically, the director of activities office/storage area lacked a required self-closing door, which had recently been removed, posing a potential risk to all residents.
Deficiencies (1)
Director of activities office/storage area was not provided with a door self-closer; the self-closing device had recently been removed, violating fire barrier enclosure requirements.
Report Facts
Census: 83
Certified beds: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding missing self-closing door during facility tour |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating Complaint Intake Number GA00229274.
Complaint Details
Complaint Intake Number GA00229274 was unsubstantiated.
Findings
The complaint was unsubstantiated, no regulatory violations were cited, and the facility was found to be in compliance with 42 CFR 483.80 infection control regulations and CMS/CDC recommended COVID-19 practices.
Report Facts
Total census: 83
Inspection Report
Deficiencies: 0
Date: Jul 29, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Autumn Lane Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 76
Deficiencies: 0
Date: Jul 29, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the previous 5/22/22 Standard Survey.
Findings
All deficiencies cited in the 5/22/22 Standard Survey were found to be corrected during the revisit survey.
Inspection Report
Life Safety
Census: 78
Capacity: 85
Deficiencies: 0
Date: Jun 2, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and the Life Safety Code standards at 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 Edition.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 3
Date: May 22, 2022
Visit Reason
A licensure survey was conducted from 5/20/2022 through 5/22/2022 at Autumn Lane Health and Rehabilitation, including investigation of Complaint Intake Number GA00216961, which was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA00216961 was investigated in conjunction with the licensure survey and was found to be unsubstantiated.
Findings
The facility was found not in substantial compliance due to failures in following care plans for residents, improper catheter care potentially contributing to urinary tract infections, failure to provide ordered dietary supplements, and inadequate environmental sanitation practices including failure to follow kill times when cleaning.
Deficiencies (3)
Failure to follow the care plan for one resident, including not providing a Mighty Shake and no added salt diet as ordered.
Failure to ensure catheter care was provided properly to prevent urinary tract infections for one resident with an indwelling catheter.
Failure to maintain sanitary and clean conditions on three of four halls, specifically not following kill times when cleaning sinks, toilets, and railings.
Report Facts
Resident census: 78
Residents sampled: 31
Residents with indwelling catheters sampled: 5
Weight loss: 17
Mighty Shake recipients: 6
Kill time for germicidal bleach wipes: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA HH | Certified Nursing Assistant | Performed catheter care on resident #61 with improper technique |
| CNA DD | Certified Nursing Assistant | Assisted with catheter care on resident #61 and interviewed about care procedures |
| Director of Nursing | Director of Nursing (DON) | Provided information about care plan procedures, staff training, and supplement administration |
| Agency Certified Nursing Assistant AA | Certified Nursing Assistant | Assisted resident #45 with lunch and confirmed use of salt on meal tray |
| Licensed Practical Nurse BB | Licensed Practical Nurse | Reported providing Boost supplement instead of ordered Mighty Shake to resident #45 |
| Food Service Manager | Food Service Manager (FSM) | Responsible for placing Mighty Shakes on meal trays and acknowledged errors |
| Housekeeper LL | Housekeeper | Observed cleaning hall rails without allowing full kill time for disinfectant |
| Housekeeper MM | Housekeeper | Observed cleaning sinks and toilets with germicidal bleach wipes and towels |
| Environmental Services Supervisor | Environmental Services Supervisor (ESS) | Provided information on cleaning protocols and spot checks |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Date: Dec 13, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00209413.
Complaint Details
Complaint number GA00209413 was investigated and determined to be unsubstantiated.
Findings
The complaint GA00209413 was found to be unsubstantiated following the investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 29, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00208973.
Complaint Details
Complaint number GA00208973 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 13, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00206927.
Complaint Details
Complaint GA00206927 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 73
Deficiencies: 0
Date: Aug 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Routine
Census: 75
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 14, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00200572.
Complaint Details
Complaint GA00200572 was investigated and determined to be unsubstantiated.
Findings
The complaint was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 66
Deficiencies: 0
Date: Oct 17, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 6, 2019 Standard Recertification Survey.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Sep 6, 2019
Visit Reason
A standard survey was conducted from 9/3/19 through 9/6/19 in conjunction with Complaint Intake Number GA00197245. The investigation was triggered by a fall incident involving Resident #2 on 4/22/19, where the resident fell from a Hoyer lift while being assisted by only one staff member instead of two.
Complaint Details
Complaint Intake Number GA00197245 was investigated in conjunction with the standard survey. The complaint involved a fall incident on 4/22/19 where Resident #2 fell from a Hoyer lift due to inadequate staff assistance. The complaint was substantiated with findings of actual harm.
Findings
The facility failed to ensure two-person assistance when using the Hoyer lift, resulting in a fall that caused a laceration to the resident's head requiring hospital transfer. The resident was assessed as high risk for falls and required two-person assistance for transfers. Staff education and policy regarding lift use were inadequate or not fully implemented, and the responsible CNA received a written warning and education after the incident.
Deficiencies (1)
Failure to have two-person assist when using the Hoyer lift, resulting in resident fall and injury.
Report Facts
Resident census: 72
Resident sample size: 18
Laceration size: 1
Date of fall incident: Apr 22, 2019
Date of survey completion: Sep 6, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA FF | Certified Nursing Assistant | Staff member who transferred resident alone resulting in fall; received written warning and education |
| Director of Nursing | Director of Nursing | Verified staffing and education issues related to Hoyer lift use |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed resident was not care planned for lift transfers until after fall |
| Administrator | Administrator | Issued written warning to CNA FF and contacted resident family |
| CNA DD | Certified Nursing Assistant | Reported receiving education on Hoyer lift use and two-person assist requirement |
| CNA EE | Certified Nursing Assistant | Reported receiving education and training on Hoyer lift use and two-person assist |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Sep 6, 2019
Visit Reason
The inspection was conducted as a licensure survey for Autumn Lane Health and Rehabilitation.
Findings
No deficiencies were identified during the licensure survey.
Inspection Report
Life Safety
Census: 64
Capacity: 85
Deficiencies: 0
Date: Sep 3, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in compliance with the Life Safety Code requirements and the Emergency Preparedness plan was also compliant with Appendix Z.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jun 4, 2019
Visit Reason
A relocation survey was conducted to provide an initial environment survey to the new Autumn Lane facility, which is a replacement facility for Gray Health & Rehabilitation.
Findings
No deficiencies were identified during the survey.
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 0
Date: Jun 14, 2018
Visit Reason
A standard survey was conducted at Gray Health and Rehabilitation from June 11, 2018 through June 14, 2018 to assess compliance with Medicaid/Medicare regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicaid/Medicare regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 56
Capacity: 58
Deficiencies: 0
Date: Jun 11, 2018
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness plan was also in substantial compliance with Appendix Z requirements.
Report Facts
Stories: 1
Construction Type: Type V(000) construction
Year Constructed: 1966
Certified beds: 58
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 12, 2017
Visit Reason
The visit was a desk review for the recertification survey originally conducted on 2017-07-23 to verify correction of previously cited deficiencies.
Findings
The review revealed that all previously cited deficiencies had been corrected and the facility was in substantial compliance as of 2017-09-06.
Inspection Report
Life Safety
Census: 57
Capacity: 58
Deficiencies: 0
Date: Jul 25, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements at 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Routine
Census: 56
Deficiencies: 1
Date: Jul 21, 2017
Visit Reason
A standard survey was conducted at Autumn Lane Health and Rehabilitation from July 21, 2017 through July 23, 2017 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to sanitary deficiencies related to the maintenance and cleaning of the ice machine, which had black residue buildup and lacked a policy for kitchen equipment maintenance.
Deficiencies (1)
Failed to ensure the ice machine was maintained in a sanitary manner; black slime-like residue was observed inside the ice machine.
Report Facts
Resident census: 56
Ice machine cleaning frequency: 30
Ice machine full sanitization frequency: 90
Ice machine age: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen Manager | Present during observation of ice machine residue and reported issue to maintenance | |
| Maintenance Director | Stated ice machine cleaning schedule and participated in inspection | |
| Administrator | Confirmed buildup was calcium deposits and lack of maintenance policies | |
| Company technician | Observed ice machine condition and confirmed need for cleaning |
Viewing
Loading inspection reports...
