Autumn Lake Healthcare at Homewood

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at Homewood, in the surveyor’s own words.

• Immediate jeopardy, isolatedF626Mar 4, 2022

  Based on medical record review and interview, the facility staff failed to allow a resident (Resident #1) to return to the facility after an emergency room visit. This was evident for 1 out of 8 residents reviewed during a complaint survey. As a result of these findings, an immediate jeopardy (IJ) was declared on 3/2/22 at 4:00 PM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to remove the immediacy on 3/2/22 at 5:41 PM and it was not accepted. The facility submitted a second plan on 3/2/22 at 6:12 PM and it was accepted by the Office of Health Care Quality at 6:15 PM. The Immediate Jeopardy was removed on 3/4/22 at 8:45 AM after on-site confirmation of the completion of the facility's plan of removal. […]

• No harm, potential for more than minimal, widespreadF730Jul 24, 2025

  Based on review of employee records and interview with facility staff, it was determined that the facility failed to 1) conduct annual performance reviews of Geriatric Nursing Assistants (GNAs) and 2) provide regular, in-service education based on the outcome of those individual performance reviews. This was evident for 5 (GNA #49, GNA #50, GNA #1, GNA #51, GNA #52) of 5 randomly selected GNAs' records reviewed during the facility's recertification survey. The findings include:Performance reviews are to be completed for every GNA at least every 12 months to identify specific in-service education based on the outcome of those individual performance reviews. […]

• No harm, potential for more than minimal, patternF867Jul 17, 2026

  Based on staff interviews and review of facility documentation it was determined the facility failed to ensure that a Performance Improvement Project (PIP) was identified and implemented through the facility's Quality Assessment and Assurance (QAA) committee and/or Quality Assurance Performance and Improvement (QAPI) program annually. This was found evident for 1 year of QAA/QAPI notes reviewed. Findings include: On 7/17/26 at 10:38 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA stated that the Assistant Director of Nursing (ADON) was responsible for running and coordinating the QAA committee. He further stated that the ADON was out of the country, and the Director of Nursing (DON) would answer any QAA/QAPI questions. […]

• No harm, potential for more than minimal, patternF868Jul 17, 2026

  Based on record review and interview, it was determined that the facility failed to maintain and account for scheduled Quality Assessment and Assurance meetings. This was evident for 5 of the 11 months QAA meetings were held July 2025- June 2026. The findings include: On 7/17/26 at 10:38 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA stated that the Assistant Director of Nursing (ADON) was responsible for running and coordinating the QAA committee. He further stated that the ADON was out of the country, and the Director of Nursing (DON) would answer any QAA QAPI questions. […]

• No harm, potential for more than minimal, patternF921Jul 17, 2026

  Based on observation and resident's interview, it was determined that the facility failed to provide a safe, functional, sanitary, comfortable and homelike environment for residents. This was evident on 3 of 4 units and 1 of 1 observation of the courtyard during the survey. The findings include: On 07/13/2026 at 8:32 AM during the initial tour of the facility, the surveyor observed that residents in rooms 46-A and B still had dirty meal trays from the previous meal sitting on their tables. […]