Autumn Lake Healthcare At Crystal Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkins, West Virginia.
- Location
- 200 Whitman Avenue, Elkins, West Virginia 26241
- CMS Provider Number
- 515197
- Inspections on file
- 20
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Crystal Springs during CMS and state inspections, most recent first.
A facility did not submit the required five-day follow-up report after investigating an allegation of sexual abuse involving a resident who lacked capacity. Although the initial report was made to authorities and interviews were conducted with the resident, staff, and other residents, the mandated follow-up documentation was not filed.
A resident received catheter care from an LPN who did not secure the urinary catheter as required by professional standards, and the facility's policy lacked guidance on catheter securement. The LPN also lifted the drainage bag above bladder level, allowing urine to flow back into the bladder before reattaching it to the bed frame.
An LPN provided urinary catheter and wound care to a resident requiring Enhanced Barrier Precautions (EBP) due to an indwelling catheter and an open wound, but failed to wear a gown as required. The LPN also did not have a plastic bag ready for soiled linens, resulting in them being dropped on the floor.
The facility did not provide clear postings or easy access to grievance forms, nor did it notify residents of their right to file grievances anonymously. Residents were generally directed to submit complaints directly to the administrator, and the only contact information provided was a compliance hotline intermittently displayed on TV screens. Interviews revealed confusion among residents about the grievance process, and there was no designated, accessible location for submitting grievances anonymously.
Surveyors found that several residents did not receive care and treatment as ordered, including a resident whose nebulizer treatment ran longer than prescribed, a resident receiving oxygen at a higher flow rate than ordered, a resident who did not receive required blood glucose monitoring after hospital return, a resident with a seizure disorder lacking padded side rails, and a resident at risk for falls whose bed was not kept in the lowest position as care planned.
The facility did not ensure RN coverage for eight consecutive hours per day on multiple sampled days, as confirmed by staff interviews and PBJ report review. The administrator acknowledged the absence of RN staff during these periods.
Staff delivered a meal tray to a resident with food items measured below the recommended serving temperatures, with hot foods such as a hotdog and fries served at just over 100°F and cold items above 40°F. The Dietary Manager acknowledged that these temperatures did not meet the required standards for hot and cold food at the point of delivery.
Surveyors found that food items in the kitchen and nourishment pantry were not properly stored, labeled, or dated, with multiple undated and unsealed items, as well as staff personal food and drinks present in resident areas. Facility policies requiring proper food storage, labeling, and separation of staff and resident items were not followed, as confirmed by interviews with the Kitchen Manager and DON.
Multiple infection control failures were observed, including staff not providing hand hygiene before meals, lack of PPE use during wound care for two residents under enhanced barrier precautions, missing water management documentation, unsanitary conditions in resident rooms and bathrooms, and unlabeled hygiene products left in shower areas. These deficiencies had the potential to impact all residents.
A resident was found with an uncovered catheter bag, and an LPN confirmed the absence of a cover. Although the facility administrator reported that sufficient catheter bag covers had been purchased for all residents who required them, there was no explanation for why this resident's catheter bag was not covered.
The facility did not post signage to inform residents and their representatives about the availability and location of survey results and plans of correction. A resident was unaware of where to find these documents, and the ADON confirmed the absence of a posted notice.
A resident who was receiving Medicare Part A skilled services and had a planned discharge did not receive the required Notice of Medicare Non-Coverage (NOMNC) form prior to the end of covered services. Although the social worker communicated with the resident's family about discharge plans and home care arrangements, the facility could not provide evidence that the NOMNC was issued as required.
A resident's bathroom was found to have a large tear in the drywall above the sink, compromising the safety and homelike quality of the environment. The issue was confirmed by an RN during an interview.
The facility did not update or accurately complete PASARR assessments for residents after new diagnoses of major mental illness, as confirmed by record review and staff interviews. Two out of three residents reviewed had new or existing mental health diagnoses that were not reflected in their PASARR documentation.
A resident reported never being asked to attend care planning meetings and not feeling included in decisions about her care. The facility administrator confirmed there was no documentation showing the resident was invited to these meetings, despite the resident's stated wish to participate in the process.
Staff did not provide required fall mats for a resident at risk for falls and allowed another resident to keep a medication in their room without a physician order or authorization for self-administration. Both situations resulted in environments that were not free from accident hazards.
The facility did not consistently post updated nurse staffing information, with the daily staffing report sheet remaining outdated for several days and the required census information missing for multiple overnight shifts. The DON confirmed these omissions during interviews.
During a facility inspection, the dumpster was found with one lid open and another lid broken and not fitting properly. An interview with the Kitchen Account Manager confirmed that dumpster lids should be closed and properly fitting, and facility policy assigns responsibility for ensuring appropriate lids to the Dining Services Director. These issues with garbage and refuse containment had the potential to affect more than an isolated number of residents.
The facility did not complete weekly skin evaluations as required by care plans for several residents, with documented gaps between assessments ranging from eight to thirty-five days. This deficiency was confirmed by the ADON and identified through both record review and staff interview.
Physician orders for weekly skin evaluations were not followed for multiple residents, with documented gaps ranging from 8 to 35 days between assessments. The ADON confirmed that these evaluations were not completed as required.
Surveyors identified that three residents had incomplete Physician Orders for Scope of Treatment (POST) forms, with missing preparer signatures, dates, and incomplete sections regarding medical interventions and nutrition. In one case, white correction fluid was used on the physician's signature area. These issues were confirmed by a social worker during staff interviews.
A resident admitted with full code status was not provided CPR when found unresponsive due to conflicting documentation and a failure by the UM to verify code status orders. The admitting nurse activated a DNR order based on instructions, and the error was not discovered until after the resident's death, when it was revealed that CPR should have been performed.
A resident receiving Seroquel and Depakote for psychosis had pharmacist recommendations for discontinuing PRN Seroquel and attempting a gradual dose reduction of Depakote. These recommendations were communicated to the physician, but there was no documented physician response or action taken, and the medication orders remained unchanged. The DON confirmed the absence of any physician response to the pharmacist's recommendations.
Failure to Submit Required Five-Day Follow-Up for Abuse Allegation
Penalty
Summary
The facility failed to submit a required five-day follow-up report for a Facility Reported Incident involving an allegation of sexual abuse. The initial allegation was reported to the appropriate authorities, including Adult Protective Services, the Ombudsman, and the Office of Inspector General, and an internal investigation was conducted. The resident involved did not have capacity and reported the incident as having occurred months prior; during a subsequent interview, she did not recall any inappropriate touching. Interviews were also conducted with the alleged perpetrator, a co-worker, and twenty additional residents with capacity, none of whom reported further allegations. Despite these investigative actions, the facility did not file the mandated five-day follow-up report, and the Administrator was unable to locate it when requested by surveyors.
Failure to Provide Catheter Care per Professional Standards
Penalty
Summary
The facility failed to provide catheter care according to professional standards of practice for one resident observed. During observation, an LPN provided urinary catheter care without securing the catheter to the resident, contrary to standard practice. When questioned, the LPN stated that the resident had a securement device but removed it himself. Additionally, the facility's catheter care policy did not include any intervention for securing the catheter. The LPN was also observed lifting the urinary drainage bag above the level of the resident's bladder, which allowed urine to flow back into the bladder before the bag was reattached to the bed frame. These actions were observed and confirmed through staff interview and policy review.
Failure to Follow Enhanced Barrier Precautions During Catheter and Wound Care
Penalty
Summary
A deficiency was identified when an LPN performed urinary catheter care and wound care for a resident who had an indwelling urinary catheter and an open wound in the right groin area, both of which required Enhanced Barrier Precautions (EBP). During the observed care, the LPN wore gloves but failed to wear a gown as required by EBP protocols. When questioned about the resident's EBP status, the LPN appeared confused before confirming that both residents were on EBP, yet still did not don a gown. Additionally, at the conclusion of care, the LPN did not have a plastic bag ready for soiled washcloths and towels, resulting in these items being dropped on the floor before a bag was provided.
Failure to Provide Accessible Grievance Policy and Anonymous Reporting
Penalty
Summary
The facility failed to establish and implement a grievance policy that meets essential regulatory requirements. There were no posted notices throughout the facility informing residents of their right to file a grievance, including the option to do so anonymously. Grievance forms were not easily accessible, and residents were not notified of their right to file grievances anonymously. Contact information for independent entities such as the state agency, Quality Improvement Organization, State Survey Agency, and State Long-Term Care Ombudsman was not clearly presented or easily accessible. Instead, residents were generally directed to submit complaints or grievances directly to the administrator, and the only contact information provided was a compliance hotline number displayed intermittently on facility TV screens. The Resident Rights sign was posted too high for wheelchair users to read, and there were no clear postings indicating the location of grievance forms. Interviews with residents revealed confusion about the grievance process, with some stating they would talk to a nurse or write a letter, and others indicating they would have to request a grievance form. The administrator stated that grievance forms were available at the nurses' station upon request and that grievances could be submitted at the nurses' station or administrator's office. However, there was no designated, easily accessible location for submitting grievances, and the only box available in the lobby was labeled "Suggestions" and was not functional for submitting documents. The administrator acknowledged that anonymity was limited due to the small size of the facility and the lack of a proper anonymous submission process.
Failure to Provide Care and Treatment According to Physician Orders and Care Plans
Penalty
Summary
Multiple deficiencies were identified in the facility's provision of treatment and care according to physician orders and residents' care plans. One resident was observed receiving a nebulizer treatment that continued to run for 40 minutes, despite the medication cup being empty after 20 minutes, exceeding the appropriate treatment duration. Another resident was found to be receiving oxygen at a flow rate of 3 liters per minute, which was higher than the physician-ordered range of 1-2 liters per minute via nasal cannula. Additionally, a resident who returned from the hospital in the evening did not have their blood glucose checked at bedtime as ordered, even though their last glucose check was several hours prior at the hospital. Further deficiencies included a resident with a seizure disorder who did not have padded side rails in place as required by physician order for seizure precautions. Another resident, identified as a fall risk with a care plan intervention to keep the bed at the lowest level at all times, was observed with the bed in a high position. Staff interviews confirmed a lack of awareness or adherence to these care requirements at the time of observation.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide sufficient and competent staffing by not ensuring Registered Nurse (RN) coverage for eight consecutive hours per day over eight sampled days. Record review and staff interviews confirmed that on specific dates, there was no RN present for the required duration. The administrator acknowledged the lack of RN coverage on these days, and review of the payroll based journal (PBJ) report corroborated the absence of RN staff during the identified periods. No information was provided regarding the involvement or condition of specific residents or patients at the time of the deficiency.
Food Served Below Safe and Appetizing Temperatures
Penalty
Summary
During a lunch meal observation, staff were seen preparing and delivering food trays to residents on the south side front hall. The meal service began at 12:37 PM, and at 12:49 PM, the temperature of a lunch tray intended to be served last was measured. The hotdog on the tray was 104.9°F, fries were 108.1°F, pineapple cake was 62.6°F, and yogurt was 59.3°F. The Dietary Manager confirmed that these temperatures did not meet the appropriate standards for serving, noting that hot foods should typically be served at 120°F or above and cold foods at 40°F or below. The Dietary Manager also stated that food leaves the kitchen at 135°F or above but was unsure of the temperature at the point of delivery to residents.
Improper Food Storage and Labeling in Kitchen and Nourishment Areas
Penalty
Summary
The facility failed to store food in accordance with professional standards and its own policies, as observed in both the main kitchen and nourishment pantry. During a tour of the kitchen, multiple bags of frozen food items, including chicken breasts, fish filets, fish patties, and french fries, were found in Freezer #1 without any dates. Additionally, frozen foods belonging to a former resident were present in the freezer without names or current best by dates. Facility policy requires all foods to be wrapped or in covered containers, labeled, and dated to prevent cross-contamination, which was not followed in these instances. Further observations in the North Hall Pantry revealed improperly stored snacks, such as Oreos in an unsealed ziplock bag with no date or name, prepackaged cookies and cakes without dates, and bowls of dry cereal with no expiration dates. The nourishment room cabinet contained staff personal items, including drinks and snacks, despite a posted sign prohibiting personal food and drink in the kitchenette. Interviews with the Kitchen Manager and DON confirmed that expired and undated food items were present and acknowledged that staff food should not have been stored in resident areas. These findings indicate a failure to adhere to facility food storage policies and professional standards.
Widespread Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies. Staff did not ensure residents received hand hygiene prior to meals, with several nursing assistants failing to offer hand sanitizer or assist with hand washing before serving lunch trays. Interviews with staff revealed uncertainty about hand hygiene practices, and it was confirmed by the Director of Nursing that hand hygiene should have been provided before meals. The facility's water management program was also deficient, lacking documentation to prevent the growth of waterborne pathogens and failing to identify areas requiring Legionella control measures. There was no evidence of regular water flushes for unused plumbing fixtures. Additionally, during wound care procedures for two residents, both a nurse practitioner and a registered nurse failed to don personal protective equipment (PPE) or follow enhanced barrier precautions, despite the residents being under such precautions. Instruments used during wound care were not disinfected between uses. Other unsanitary practices were observed, including a toilet seat with a brown substance left in a resident's bathtub for over a day, an uncleaned room with tube feeding supplies left out after a resident was transferred to the hospital, and unlabeled hygiene product bottles left in shower rooms. These lapses in infection control and environmental sanitation had the potential to affect all residents in the facility.
Uncovered Catheter Bag Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a resident was observed with an uncovered catheter bag during an interview. The observation took place on 03/03/2025 at 2:46 PM, and it was confirmed by an LPN at 2:44 PM that the catheter bag did not have a cover. The facility administrator later stated that catheter bag covers had been purchased for all residents who needed them but was unable to explain why this particular resident did not have one. The facility census at the time was 77 residents.
Failure to Post Notice of Survey Results Availability
Penalty
Summary
The facility failed to display notices regarding the availability of survey results and related plans of correction in areas that are prominent and easily accessible to residents and their representatives. During an observation, there was no signage posted to indicate where survey results could be reviewed. Although the Administrator stated that the survey results were available in a binder near the entrance, this was not clearly communicated to residents. During a resident council meeting, a resident expressed unawareness of the location or relevance of the survey results, and the ADON confirmed that no notice was posted to inform residents or their representatives about the availability of these documents.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) letter to one of three residents reviewed during the annual survey process. Specifically, a resident began Medicare Part A skilled services and had a planned discharge, with the last covered day of Part A service documented. However, there was no evidence in the records that the NOMNC form was given to the resident prior to the end of covered services. Social service notes confirmed communication with the resident's daughter regarding the upcoming discharge and arrangements for home therapy and oxygen, but the facility was unable to verify that the NOMNC form was provided as required.
Damaged Bathroom Wall Compromises Resident Environment
Penalty
Summary
A deficiency was identified when a surveyor observed a large, rectangular tear in the drywall of a resident's bathroom wall, measuring approximately 11 inches wide by 8 inches long, located to the left of the sink. This observation was made during a routine entry into the bathroom. The presence of the damaged wall indicated that the environment was not maintained in a safe, clean, comfortable, and homelike condition as required. The issue was acknowledged by a registered nurse during an interview, confirming the existence of the tear in the drywall.
Failure to Update PASARR Assessments After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASARR) assessments were updated or accurately completed following new diagnoses of major mental illness for multiple residents. For one resident, the PAS completed did not reflect new diagnoses of unspecified psychosis and major depressive disorder, and the Director of Social Services confirmed that no new PASARR had been completed after these diagnoses. Another resident had a diagnosis of unspecified psychosis, but the PAS completed did not capture this diagnosis, and although a new PASARR was reportedly completed, it failed to include the updated information. A third resident was admitted with major depressive disorder and schizoaffective disorder, but the PAS did not indicate these diagnoses, and the Director of Social Services acknowledged that the major depressive disorder was not captured and a new PAS was not completed. These deficiencies were identified through record review and staff interviews, which revealed that the facility did not coordinate or update PASARR assessments as required when residents received new or updated diagnoses of major mental illness. The failure to accurately document and update PASARR assessments was observed in two out of three residents reviewed for this category, despite the presence of relevant mental health diagnoses in their medical records.
Failure to Document Resident Invitation to Care Plan Meetings
Penalty
Summary
The facility failed to provide evidence that residents were invited to participate in their care plan meetings, as required. Specifically, one resident reported during an interview that she had never been asked to attend her care planning meetings and did not feel included in the decision-making process regarding her care. The facility administrator confirmed that there was no documentation to support that this resident had been invited to care plan meetings, despite the resident's expressed desire to be involved, as indicated in her Minimum Data Set (MDS) assessment. The administrator also acknowledged that the facility had previously been cited for this issue and lacked current documentation of compliance.
Failure to Prevent Accident Hazards and Ensure Safe Medication Storage
Penalty
Summary
Staff failed to ensure that two resident environments were free from accident hazards as required. For one resident with a history of CVA, contractures, and inability to ambulate or transfer independently, fall mats were not present at the bedside as ordered by the physician, a fact confirmed by a nurse aide. The care plan for this resident specifically identified a risk for falls and required fall mats to be in place while the resident was in bed. In a separate incident, another resident was found to have a bottle of Derma-[NAME] containing hydrocortisone cream in their bathroom without a physician order for self-administration or for the medication itself. The product's material safety data sheet indicated it was not intended for oral or ophthalmic use and could cause irritation or harm if misused. A registered nurse confirmed the medication should not have been in the resident's room.
Failure to Post Updated Nurse Staffing Information and Census
Penalty
Summary
The facility failed to ensure that updated nurse staffing information was posted daily as required. On 03/03/2025, the posted daily staffing report sheet was found to be outdated by five days, displaying the date 02/26/2025 instead of the current date. This was confirmed by the Director of Nursing (DON) during an interview. Additionally, the facility did not include the census on the nurse staffing data at the beginning of each shift for eight sampled days, specifically for the 7:00 PM - 7:00 AM shift on multiple dates. The DON acknowledged that the census was not listed on these occasions.
Improper Disposal and Containment of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a facility tour when the dumpster was found with one lid open and another lid broken and not fitting properly. During an interview, the Kitchen Account Manager confirmed that dumpster lids should be closed and properly fitting. A review of the facility's policy indicated that the Dining Services Director is responsible for ensuring appropriate lids are provided for all containers. These lapses in maintaining garbage and refuse containers in good condition and ensuring waste was properly contained had the potential to affect more than an isolated number of residents. The facility census at the time was 77.
Failure to Complete Weekly Skin Evaluations per Care Plan
Penalty
Summary
The facility failed to implement care plan interventions requiring weekly skin evaluations for four out of five residents reviewed during the survey process. Record reviews for these residents revealed multiple instances where the interval between documented skin evaluations exceeded seven days, with gaps ranging from eight to thirty-five days. These lapses were confirmed by the Assistant Director of Nursing, who acknowledged that the weekly skin evaluations were not being completed as required by the residents' care plans. Specifically, the records for each resident showed repeated occurrences of missed or delayed skin assessments, with some intervals extending up to 35 days between evaluations. The deficiency was identified through both record review and staff interview, and it was consistently observed across multiple residents, indicating a pattern of non-compliance with the established care plan interventions for skin integrity monitoring.
Failure to Complete Weekly Skin Evaluations per Physician Orders
Penalty
Summary
The facility failed to follow physician's orders for weekly skin evaluations for four out of five residents reviewed for quality of care. Record reviews for these residents showed multiple instances where the interval between documented skin evaluations exceeded seven days, contrary to the prescribed weekly schedule. Specific gaps ranged from 8 to 35 days between evaluations, as evidenced by the documented dates in the residents' medical records. During staff interviews, the Assistant Director of Nursing confirmed that the weekly skin evaluations were not being completed as ordered for the affected residents. This deficiency was identified through both record review and staff confirmation, with no evidence provided in the report that the residents' preferences or goals were considered in the omission of these evaluations.
Incomplete and Altered POST Forms in Resident Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three of five residents reviewed during the survey. For one resident, the Physician Orders for Scope of Treatment (POST) form was found to be incomplete, with the preparer's signature and date left blank. Another resident's POST form had white correction fluid applied over the physician's signature area, and the preparer's signature and date were also missing. A third resident's POST form was incomplete in multiple sections, including those specifying medical intervention choices and medically administered fluids and nutrition, as well as lacking the preparer's signature and date. These deficiencies were confirmed by the facility's social worker during staff interviews. The findings were based on record reviews and staff interviews, and the facility census at the time was 82.
Failure to Honor Resident Code Status Due to Order Verification Lapse
Penalty
Summary
The facility failed to honor the code status of a resident who was admitted with full code orders, meaning CPR was to be initiated if needed. Upon admission, there were conflicting documents: the hospital discharge summary indicated full code, while a POST form indicated DNR. The Unit Manager queued orders in the computer system and instructed the admitting nurse to activate them, stating she would verify their accuracy the following morning. The admitting nurse activated the DNR order, which was also signed by the facility physician, but the Unit Manager did not verify the orders as intended and assumed the hospital's full code order was incorrect. When the resident was found unresponsive with no pulse or respirations, CPR was not attempted, and emergency services were called, after which the resident was pronounced dead. The facility did not contact the hospital or the resident's wife to clarify the conflicting code status orders. The error was discovered only after the resident's wife was informed of his passing, revealing that CPR should have been performed according to the correct code status.
Failure to Ensure Physician Response to Pharmacist Medication Review
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and documented a response to irregularities identified by the consultant pharmacist for one of six resident records reviewed. Specifically, a resident was prescribed Seroquel and Depakote for psychosis, and the consultant pharmacist made recommendations regarding the discontinuation of PRN Seroquel and a gradual dose reduction (GDR) for Depakote. The pharmacist's recommendations were communicated to the physician, but there was no documented response from the physician regarding these recommendations. Record reviews showed that the pharmacist's suggestions were faxed to the physician, and although the physician later performed a history and physical and medication review for the resident, there was no documentation addressing the pharmacist's recommendations. The orders for the medications remained unchanged, and the facility's DON confirmed that no physician response to the pharmacist's recommendations was present in the records. This failure was cited under federal regulations requiring that pharmacist-identified irregularities be reported and acted upon by the attending physician.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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