Inspection Report
Re-Inspection
Census: 39
Capacity: 75
Deficiencies: 1
Jun 24, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/28/25 was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in substantial compliance with Medicare/Medicaid participation requirements and Life Safety Code standards. One deficiency was noted regarding a corridor door to the Beauty Shop lacking a positive latching mechanism, which was corrected during the revisit.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The corridor door to the Beauty Shop lacked positive latching hardware and failed to latch into the door frame. | SS=B |
Report Facts
Facility capacity: 75
Census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Wolfe | Executive Director | Signed the report |
Inspection Report
Annual Inspection
Deficiencies: 0
May 22, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey completed on March 31, 2025.
Findings
Autumn Ridge Rehabilitation Centre was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 37
Capacity: 75
Deficiencies: 5
Apr 28, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including self-closing corridor doors for hazardous storage areas, overdue maintenance on portable fire extinguishers, malfunctioning smoke barrier doors, lack of GFCI protection on electrical outlets near sinks, and use of power cord daisy chains. Corrective actions and plans for ongoing compliance monitoring were documented.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure corridor doors to a beauty shop used for storage had self-closing and latching devices. | SS=E |
| Two portable fire extinguishers had not received required 6-year maintenance. | SS=E |
| Dining room smoke barrier doors did not restrict smoke movement due to malfunctioning coordinating device. | SS=E |
| One receptacle within 6 feet of a sink in the dining room was not GFCI protected. | SS=E |
| Two power cord daisy chains were used as a substitute for fixed wiring in the IT closet. | SS=E |
Report Facts
Facility capacity: 75
Census: 37
Portable fire extinguishers: 2
Portable fire extinguishers total: 11
Residents affected by corridor door deficiency: 20
Residents affected by fire extinguisher deficiency: 25
Residents affected by smoke barrier door deficiency: 25
Residents affected by GFCI deficiency: 30
Residents affected by power cord daisy chain deficiency: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and involved in findings and corrective actions | |
| Administrator | Interviewed and involved in findings and exit conference |
Inspection Report
Annual Inspection
Census: 41
Capacity: 41
Deficiencies: 5
Mar 31, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 25 to March 31, 2025.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity related to call light response times, inadequate ADL care such as nail grooming, failure to provide bedtime snacks consistently, and lapses in infection prevention and control practices including hand hygiene during laundry delivery and failure to use enhanced barrier precautions for a resident with a central line.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to protect a resident's dignity by not responding timely to a request for assistance with bed mobility for toileting needs. | SS=D |
| Failed to provide daily grooming assistance for nail care for a dependent resident. | SS=D |
| Failed to offer and/or provide bedtime snacks to 6 of 6 residents reviewed. | SS=D |
| Failed to utilize infection prevention and control practices related to hand hygiene during laundry delivery affecting 38 of 41 residents. | SS=D |
| Failed to utilize infection prevention and control practices related to enhanced barrier precautions during care for 1 of 3 residents reviewed for infection control (Resident 32). | SS=D |
Report Facts
Residents reviewed for dignity: 41
Residents reviewed for ADLs: 3
Residents reviewed for frequency of meals: 6
Residents receiving facility laundry services: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Wolfe | Laboratory Director or Provider/Supplier Representative | Signed the report. |
| LPN 3 | Observed flushing central line without additional PPE and not following enhanced barrier precautions for Resident 32. | |
| CNA 9 | Failed to respond timely to Resident 194's request for repositioning. | |
| CNA 10 | Assisted Resident 194 with repositioning after delay. | |
| CNA 8 | Responsible for cutting nails of non-diabetic residents and reported on nail care practices. | |
| Laundry Aide 11 | Observed failing to perform hand hygiene during laundry delivery. | |
| DON | Director of Nursing | Provided interviews regarding call light expectations, nail care, infection control policies, and enhanced barrier precautions. |
| Administrator | Indicated lack of policy on call light response and nail care; provided facility policies. | |
| Assistant Housekeeping and Laundry Supervisor | Provided laundry and linen handling policies and procedures. |
Inspection Report
Life Safety
Census: 35
Capacity: 75
Deficiencies: 0
Aug 21, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey that exited on 07/12/24 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Autumn Ridge Rehabilitation Centre was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with a fire alarm system and smoke detection throughout.
Report Facts
Facility capacity: 75
Census: 35
Inspection Report
Life Safety
Census: 33
Capacity: 75
Deficiencies: 9
Jul 12, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 07/12/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Multiple deficiencies were identified related to exit door accessibility, stairwell door latching, hazardous storage, alcohol-based hand sanitizer placement, sprinkler system maintenance, corridor door latching, and fire drill documentation.
Severity Breakdown
SS=F: 3
SS=E: 5
SS=C: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure all exterior exit doors were readily accessible and able to open on first try. | SS=F |
| Failed to ensure the means of egress for 3 exit doors was readily accessible without requiring specialized security measures. | SS=F |
| Latch on 3rd floor stairwell exit door near RR# 309 was not functioning and door failed to self-close and latch. | SS=E |
| Failed to ensure corridor doors to 2 hazardous rooms had self-closing devices that properly closed and latched. | SS=E |
| One alcohol-based hand sanitizer dispenser was installed directly above a light switch, an ignition source. | SS=E |
| Failed to maintain automatic sprinkler system; Post Indicator Valve sight glass was unreadable. | SS=C |
| One alcove used as hazardous storage with combustible materials open to corridor. | SS=E |
| One corridor door (Resident Room #304) failed to latch positively into the door frame. | SS=E |
| Failed to conduct fire drills on each shift for 1 of 4 quarters; missing documentation for second and third shift drills in Q4 2023. | SS=F |
Report Facts
Facility capacity: 75
Census: 33
Deficiency count: 9
Fire drill missing shifts: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Wolfe | Executive Director | Named in relation to findings and exit conference |
Inspection Report
Renewal
Census: 33
Capacity: 33
Deficiencies: 3
Jun 18, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over June 12, 13, 14, 17, and 18, 2024.
Findings
The facility was found deficient in several areas including failure to provide Medicare non-coverage notifications to residents, inadequate assistance with grooming and timely showers for dependent residents, and use of unqualified staff assisting residents with eating.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide notification of Medicare non-coverage for 2 of 3 residents reviewed for beneficiary protection notifications. | SS=D |
| Failed to provide grooming and dressing assistance and failed to perform timely showers for 2 of 3 residents reviewed for activities of daily living. | SS=D |
| Failed to ensure qualified staff assisted residents with eating for 1 of 3 mealtime observations; an uncertified activity assistant assisted a resident with eating. | SS=D |
Report Facts
Census: 33
Total Capacity: 33
Residents reviewed for Medicare non-coverage notification: 3
Residents affected by Medicare non-coverage notification deficiency: 2
Residents reviewed for ADL care: 3
Residents affected by ADL care deficiency: 2
Mealtime observations: 3
Residents affected by feeding assistance deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Doug Lynch | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Activity Assistant 10 | Activity Assistant | Assisted resident with eating without passing CNA written certification |
| Administrator | Interviewed regarding Medicare non-coverage notification and facility policies | |
| Social Services Director | Interviewed regarding notification of Medicare non-coverage and documentation | |
| DON | Director of Nursing | Interviewed regarding grooming, shower refusals, and feeding assistant qualifications |
| CNA 5 | Certified Nursing Assistant | Interviewed regarding documentation of resident refusals for care |
| CNA 7 | Certified Nursing Assistant | Interviewed regarding resident refusals and shower documentation |
| CNA 8 | Certified Nursing Assistant | Interviewed regarding resident grooming, shower refusals, and feeding assistance |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 18, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Autumn Ridge Rehabilitation Centre was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 40
Capacity: 40
Deficiencies: 0
Dec 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423284.
Findings
No deficiencies related to the allegations in Complaint IN00423284 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00423284 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 40
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 14
Total Census: 40
Inspection Report
Complaint Investigation
Census: 38
Capacity: 38
Deficiencies: 0
Oct 11, 2023
Visit Reason
This visit was for the investigation of complaints IN00419470, IN00419034, and IN00419042.
Findings
No deficiencies related to the allegations in complaints IN00419470, IN00419034, and IN00419042 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00419470, IN00419034, and IN00419042 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 38
Total Capacity: 38
Census Payor Type Medicaid: 29
Census Payor Type Other: 9
Inspection Report
Life Safety
Census: 37
Capacity: 75
Deficiencies: 0
Jul 13, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/15/23 by the Indiana Department of Health.
Findings
At this Life Safety Code Survey, Autumn Ridge Rehabilitation Center was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Annual Inspection
Census: 36
Capacity: 75
Deficiencies: 6
Jun 15, 2023
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid and Life Safety Code requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including self-closing doors, maintenance of battery-operated smoke alarms, monthly inspection of fire extinguishers, protection of electrical junction boxes, and proper use of power strips and extension cords. Corrective actions were initiated during the survey.
Severity Breakdown
SS=E: 4
SS=F: 1
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 therapy horizontal exit door is self-closing and kept closed unless held open by a compliant release device. | SS=E |
| Failed to ensure all battery operated smoke alarms in resident rooms were maintained and replaced if older than 10 years. | SS=F |
| Failed to inspect 1 of 1 portable fire extinguishers on the patio monthly; missing documentation from September 2022 through May 2023. | SS=D |
| Failed to ensure 1 of 1 electrical junction boxes in attic above resident room 319 was protected with a cover; exposed wiring observed. | SS=E |
| Failed to ensure 1 of 1 power strip was not used as a substitute for fixed wiring to provide power to high current draw equipment (refrigerator in resident room 326). | SS=E |
| Failed to ensure 11 resident rooms did not use flexible cords (lamps with powered plugs in base) as a substitute for fixed wiring. | SS=E |
Report Facts
Facility capacity: 75
Census: 36
Residents potentially affected by therapy door deficiency: 5
Number of resident rooms with extension cord lamp issues: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Patton | Executive Director | Named as facility representative at exit conference |
| Maintenance Director | Interviewed and acknowledged multiple deficiencies including door, smoke alarms, fire extinguisher, electrical issues, and power strip usage |
Inspection Report
Renewal
Census: 38
Capacity: 38
Deficiencies: 0
Jun 6, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over May 31, June 1, 2, 5, and 6, 2023.
Findings
Autumn Ridge Rehabilitation Centre was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 25
Census Payor Type - Other: 11
Inspection Report
Complaint Investigation
Census: 42
Capacity: 42
Deficiencies: 0
Mar 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00403144.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00403144 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 42
Total Capacity: 42
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 27
Census Payor Type - Other: 14
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 28, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00386966 completed on August 19, 2022.
Findings
Autumn Ridge Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00386966 completed on August 19, 2022; facility found in compliance.
Inspection Report
Re-Inspection
Census: 45
Capacity: 75
Deficiencies: 0
Sep 8, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/19/22 by the Indiana Department of Health.
Findings
At this PSR survey, Autumn Ridge Rehabilitation Centre was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility was fully sprinklered except for two detached sheds used for storage.
Report Facts
Facility capacity: 75
Census: 45
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 1
Aug 18, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00386966, which was substantiated with federal/state deficiencies cited related to the allegations.
Findings
The facility failed to ensure an incident of resident-to-resident verbal abuse was reported immediately to the Executive Director and submitted to the State Agency within the required timeframe for 1 of 5 resident incidents reviewed. The investigation revealed that the abuse was reported late to the Executive Director and subsequently to the State Agency.
Complaint Details
Complaint IN00386966 was substantiated. The facility failed to timely report an incident of resident-to-resident verbal abuse involving Resident F and Resident C. The Executive Director reported the incident to the State Agency on 7/21/22 after a delay.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an incident of resident to resident verbal abuse immediately to the Executive Director and State Agency as required. | SS=D |
Report Facts
Census: 50
Total Capacity: 50
Residents involved in incident: 2
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