Cycle 1
Health 2025-05-16 · Fire 2025-05-16
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Gray, GA
Autumn Lane Health And Rehabilitation
4-star overall rating with 4-star inspections with 3 recent health deficiencies
302 Georgia 18 East, Gray, GA
(478) 986-3151
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
81
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1989-11-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
48 facilities
Chain averages 4 overall / 4 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.37
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.58
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,093
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9906
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.46
Baseline 45.45% · Performance 45.45% · Measure score 4.46 · Achievement 4.46 · Improvement 0
Adjusted total nurse staffing
3.02
Baseline 3.67 hours · Performance 3.94 hours · Measure score 3.02 · Achievement 3.02 · Improvement 0.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.22% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 6.93% |
| Discharge to community | 48.25% |
50.57%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 40% · Lower 95% interval 33.35% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 94.59% |
95.27%
0.7 pts worse
|
Numerator 35 · Denominator 37 |
| Falls with major injury | 8.11% |
0.77%
7.3 pts worse
|
Numerator 3 · Denominator 37 |
| Discharge self-care score | 3.45% |
53.69%
50.2 pts worse
|
Numerator 1 · Denominator 29 |
| Discharge mobility score | 24.14% |
50.94%
26.8 pts worse
|
Numerator 7 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 10.81% |
2.29%
8.5 pts worse
|
Numerator 4 · Denominator 37 · Adjusted rate 9.63% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 121 |
| Staff flu vaccination coverage | 42.02% |
42%
About the same
|
Numerator 50 · Denominator 119 |
| Discharge function score | 3.45% |
56.45%
53 pts worse
|
Numerator 1 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 45.45% |
25.2%
20.3 pts better
|
Numerator 10 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.5 |
2.2
2.3 pts worse
|
1.9
2.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.5 · Observed 3.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.0
1.4 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.2%
8.5 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.7% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
95.0%
3.7 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.2%
0.6 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.1% · Q3 0.0% · Q4 1.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
9.6%
8.9 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
5.9%
2.8 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 10.3% · Q3 10.4% · Q4 4.5% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.9% |
20.7%
1.8 pts better
|
19.6%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 20.3% · Q3 18.6% · Q4 18.8% · 4Q avg 18.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
21.4%
12.3 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 10.9% · Q3 6.9% · Q4 9.1% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.5% |
17.9%
9.4 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 5.7% · Q3 10.0% · Q4 7.4% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
16.2%
8.6 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 7.7% · Q3 9.2% · Q4 6.2% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.1%
0.4 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.9% · Q3 1.3% · Q4 0.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.5%
2.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.8% |
16.1%
11.3 pts better
|
19.8%
15 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.4% · Q3 5.0% · Q4 3.8% · 4Q avg 4.8% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
6.2%
0.8 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 9.1% · Q3 5.5% · Q4 2.6% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
80.4%
19.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
12.2%
4.7 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 17.2% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.2%
21.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
24.2%
0.8 pts better
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 24.1% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-24 · Fire 2023-09-24
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-05-22 · Fire 2022-05-22
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-09-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-27
F · Potential for more than minimal harm
2023-09-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-03
D · Potential for more than minimal harm
2022-05-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-30
Penalties and ownership
What sits behind the stars
Ownership
Community Health Systems Inc
5% Or Greater Indirect Ownership Interest · Organization
Health Scholarships Inc
5% Or Greater Direct Ownership Interest · Organization
Clinical Services Inc
Operational/Managerial Control · Organization
Davis, Gregory
Operational/Managerial Control · Individual
Law, Valerie
Operational/Managerial Control · Individual
Patel, Maulikkumar
Operational/Managerial Control · Individual
Whipple, Kendra
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lynn Haven Health And Rehabilitation
Gray, GA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Pruitthealth - Eastside
Macon, GA
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
PruittHealth - Lakeside, LLC
Macon, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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