Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Transitions Healthcare Autumn Grove Care Center during CMS and state inspections, most recent first.
Staff failed to follow proper glove use and hand hygiene during food preparation, handling multiple food items with the same gloves after touching potentially contaminated surfaces. Additionally, food items in a unit pantry refrigerator and freezer were not labeled with resident names or dates, and the refrigerator was found to be unsanitary. These actions were confirmed by dietary staff and an LPN.
The facility did not maintain an effective pest control program in one pantry, where numerous small flying insects were observed on surfaces and around the baseboard. An LPN confirmed the ongoing issue, and the facility could not provide evidence of prior pest control treatment in that area.
A resident with multiple medical conditions, including bipolar disorder, was prescribed PRN Lorazepam for 45 days without documented physician rationale for exceeding the facility's 14-day limit for PRN psychotropic medications. Review of the clinical record and confirmation by the Nursing Home Administrator showed no justification for the extended order.
The facility did not meet the required NA to resident ratios, failing to provide one NA per 10 residents during the day, one per 11 in the evening, and one per 15 overnight. This deficiency was noted over several days, with the Nursing Home Administrator confirming the staffing shortfalls.
The facility did not meet the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period on one day, providing only 3.10 hours. This was confirmed by the Nursing Home Administrator after reviewing staffing documents.
The facility failed to store food safely in two nourishment refrigerators, with observations revealing unlabeled, undated, and outdated food items, as well as unsanitary conditions. The Dietary Manager confirmed these issues, indicating non-compliance with facility policies on food storage and sanitation.
The facility failed to provide a dignified dining environment for three residents with severely impaired cognition, who were observed eating meals in the hallway due to lack of space in the main dining area. Interviews confirmed that the dining area was at capacity, and the resident lounge was closed during meals, leading to this arrangement.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect documentation of insulin administration. Despite being prescribed antihyperglycemic medications Liraglutide and Trulicity, which are not classified as insulin, the MDS assessments inaccurately recorded insulin administration. The Registered Nurse Assessment Coordinator confirmed these coding errors.
A facility failed to maintain proper care of respiratory equipment for a resident with COPD, dementia, and high blood pressure. The resident's oxygen concentrator filter, which was supposed to be cleaned weekly, was observed to have a gray dusty substance on two consecutive days. An LPN confirmed the filter's unclean state, indicating non-compliance with the facility's policy for maintaining respiratory equipment.
A facility failed to maintain communication records with a dialysis center for a resident with end-stage renal disease. Despite policies requiring communication before each dialysis session, there was no evidence of communication for 16 visits over a month. The Executive Director confirmed the lack of records, indicating a failure to follow established protocols.
Failure to Maintain Safe and Sanitary Food Handling and Storage
Penalty
Summary
The facility failed to maintain safe and sanitary food handling and storage practices as required by its own policies and professional standards. During tray line observation, a dietary employee was seen leaving the kitchen with gloved hands, retrieving a can of soup from a storeroom, opening and preparing the soup, and then proceeding to handle hamburger buns, cheese slices, and grilled cheese sandwiches with the same pair of gloves. The employee did not change gloves or wash hands after touching potentially contaminated surfaces, such as the soup can and storeroom door, before directly handling ready-to-eat food items. The dietary employee acknowledged the lapse and stated that glove changes and handwashing were not performed as required in this instance. The dietary manager confirmed that the employee should have changed gloves and washed hands after handling the soup can. Further observations revealed that food items stored in the CD unit pantry refrigerator and freezer were not labeled with resident names or use-by dates, as required by facility policy. Specifically, a bottle of Diet Pepsi, a can of energy drink, and a bowl of applesauce were found without proper labeling. Additionally, the refrigerator was found to be unsanitary, with a dried yellow substance present on the shelves. An LPN confirmed that the refrigerator was dirty and contained unlabeled items, in violation of facility policy and food safety standards.
Failure to Maintain Effective Pest Control in Pantry
Penalty
Summary
The facility failed to maintain an effective pest control program in the CD Unit pantry, as required by its own policy. During an observation, numerous small flying insects were seen on the walls, around the sink, garbage can, and at the base of the floor where a section of baseboard was coming off. An LPN confirmed the persistent presence of these insects in the pantry and noted that the problem worsens when food is left on the counters. The facility was unable to provide any evidence of prior pest control treatment for the CD pantry.
Lack of Physician Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of a PRN psychotropic medication beyond the 14-day limit for one resident. According to facility policy, PRN psychotropic medications should be limited to 14 days unless a longer duration is justified by the attending physician or prescribing practitioner. A resident with diagnoses including bipolar disorder, liver failure, difficulty eating, gall stones, and heart disease was prescribed Lorazepam every six hours as needed for 45 days. Review of the clinical record showed no documented physician rationale for extending the PRN order past 14 days. The care plan referenced the use of anti-anxiety medications and noted the PRN order for Lorazepam, but there was no supporting documentation for the extended duration. The Nursing Home Administrator confirmed the absence of a physician's rationale for the extended PRN order.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios as mandated by regulations effective July 1, 2024. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents overnight. This deficiency was observed over multiple days within the review period from November 18, 2024, to December 18, 2024. The facility's staffing documents revealed shortages on seven days for the day shift, eight days for the evening shift, and three days for the overnight shift. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the facility's failure to meet the required staffing ratios on the specified dates and shifts. The census data indicated that the number of NAs working was consistently below the required number based on the resident census, leading to the deficiency in staffing levels. This shortfall in staffing was documented through a review of the facility's nursing staffing documents and was corroborated by staff interviews.
Plan Of Correction
1. The facility cannot go back to correct identified days when the nurse aide ratio was less than required for each shift. No adverse outcomes when the nurse aide ratio was less than required per interviews with clients. 2. A daily staff hour/ratio worksheet will be utilized, which has the staff ratio calculator function on it. 3. Administrator/Director of Nursing will educate staffing coordinators and RN charge nurses the week of Jan 13th on: - How to use the daily staffing sheet with ratios - How to replace call offs when needed - Notifications to the appropriate Interdisciplinary Team members when staffing does not meet ratios 4. Daily staffing meeting will be implemented with the administrator/Director of Nursing/staffing coordinator or designee to review staffing and appropriate ratios. Minutes will be taken for each meeting. 5. Administration will review agency contracts to ensure they are up to date. 6. Ratio audit will be completed by Administrator or designee 5 days a week x 4 weeks then: - 3 days a week x 2 weeks then weekly thereafter 7. Audits will be taken to Quality Assurance and Performance Improvement Committee for review/discussion.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period on one of the days reviewed, specifically on 11/24/24. A review of the nursing staffing documents for the periods from 11/18/24 to 11/24/24, 12/5/24 to 11/11/24, and 12/12/24 to 12/18/24 revealed that on 11/24/24, the facility provided only 3.10 hours of direct care per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on 12/19/24, who verified the accuracy of the staffing information and acknowledged the failure to meet the required care hours on the specified date.
Plan Of Correction
1. The facility cannot go back to correct identified days when the nurse aide ratio was less than required for each shift. No adverse outcomes when the nurse aide ratio was less than required per interviews with clients. 2. A daily staff hour/ratio worksheet will be utilized, which has the staff ratio calculator/nursing care hours function on it. 3. Administrator/Director of Nursing will educate staffing coordinators and RN charge nurses the week of Jan 13th on: - How to use the daily staffing sheet with ratios and nursing care hours - How to replace call offs when needed - Notifications to the appropriate Interdisciplinary Team members when staffing does not meet ratios and/or nursing care hours 4. Daily staffing meeting will be implemented with the administrator/Director of Nursing/staffing coordinator or designee to review staffing and appropriate ratios and nursing care hours. Minutes will be taken for each meeting. 5. Administration will review agency contracts to ensure they are up to date. 6. Ratio/nursing care hours audit will be completed by Administrator or designee: - 5 days a week x 4 weeks then - 3 days a week x 2 weeks then weekly thereafter 7. Audits will be taken to Quality Assurance and Performance Improvement Committee for review/discussion.
Failure to Maintain Safe and Sanitary Food Storage
Penalty
Summary
The facility failed to store food and food containers in a safe and sanitary manner in two nourishment refrigerators located on the A/B Unit and C/D Unit. Observations revealed that the pantry refrigerator on the A/B Unit contained several food items without a resident name or date, including a clear plastic container labeled as ham salad, a white plastic bowl with a rice and corn mixture, a red bag with deli meat and cheese, and a container of fresh cut vegetables with a best if used by date that had already passed. Similarly, the pantry refrigerator on the C/D Unit contained a white foam container with chicken tenders and a Chinese take-out container with a date from over two weeks prior. Additionally, there were several items lacking a name and date, such as pizza boxes, a black plastic container with meat, a submarine sandwich, a croissant, a lunch pail with drinks and a sandwich, and a drink cup with pop. The refrigerator also had dried spills, food crumbs, and debris on the shelves and bottom. The facility's policies required that food and beverages be labeled and dated to ensure food safety, and that food and nutrition services staff clean and sanitize refrigerators regularly. However, during an interview, the Dietary Manager confirmed the presence of outdated, unlabeled, and undated food items in both refrigerators, as well as the unsanitary condition of the C/D Unit refrigerator. This indicates a failure to adhere to the facility's policies regarding food storage and sanitation, leading to the observed deficiencies.
Inadequate Dining Arrangements for Residents
Penalty
Summary
The facility failed to provide an environment that enhances the quality of life for three residents, as evidenced by the lack of a physician's order or plan of care for residents consuming meals in the hallway at the nurse's station. Resident R25, with diagnoses including bipolar disorder, dementia, and cognitive communication deficit, was observed being fed by staff in the hallway. Similarly, Resident R65, diagnosed with dementia and mood disorder, and Resident R69, with Alzheimer's disease and psychotic disorder, were observed feeding themselves in the hallway. All three residents had severely impaired cognition as indicated by their BIMS scores. The observations revealed that the main dining area was at maximum capacity, and the resident lounge was not open during meals due to a previous choking incident. Consequently, residents who could not eat in their rooms were required to eat in the hallway. Interviews with the Registered Nurse and the Executive Director confirmed the lack of space in the dining area, leading to this arrangement. The facility's failure to provide a suitable dining environment for these residents was a deficiency in honoring their right to a dignified existence and self-determination.
Inaccurate MDS Assessments for Insulin Administration
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents, leading to a deficiency. Resident R15, who was admitted with diagnoses including Type II diabetes, breast cancer, and dementia, had an MDS assessment that incorrectly indicated insulin administration. The clinical records showed that Resident R15 was prescribed Liraglutide and Trulicity, both antihyperglycemic medications not classified as insulin. Despite this, the admission MDS and quarterly MDS inaccurately recorded insulin administration for Resident R15. Similarly, Resident R32, admitted with conditions such as morbid obesity, heart failure, and hyperglycemia, was also affected by incorrect MDS coding. The clinical records indicated a prescription for Trulicity, yet the quarterly MDS inaccurately noted insulin administration. During an interview, the Registered Nurse Assessment Coordinator confirmed the coding errors, acknowledging that neither Liraglutide nor Trulicity should have been recorded as insulin in the MDS assessments for these residents.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment for a resident, identified as R66, who was receiving respiratory services. The facility's policy required cleaning of oxygen concentrator filters weekly to ensure optimal function and infection control. Resident R66, who had chronic obstructive pulmonary disease (COPD), dementia, and high blood pressure, had a physician's order for oxygen at three liters per minute via nasal cannula, with the filter to be cleaned weekly. However, observations on two consecutive days revealed that the oxygen concentrator's filter contained a gray dusty substance, indicating it had not been cleaned as required. This was confirmed by an LPN during an interview, acknowledging the presence of dust on the filter.
Failure to Maintain Dialysis Communication Records
Penalty
Summary
The facility failed to maintain proper communication records between the nursing home and the dialysis center for a resident requiring dialysis services. According to the dialysis contract and facility policy, the nursing home staff is responsible for assessing the resident's physical condition and communicating their stability for outpatient dialysis to the dialysis center before each transfer. Additionally, the dialysis center is expected to provide the facility with reports and information necessary for the resident's care plan. However, for Resident R79, who has end-stage renal disease and receives dialysis three times a week, there was no evidence of communication from the facility to the dialysis center for 16 visits between July 15 and August 22, 2024. The deficiency was confirmed during an interview with the Executive Director, who acknowledged the lack of communication records for Resident R79 since July 15, 2024. The facility's policy requires that communication occur for each dialysis treatment and that evidence of this communication be maintained in the resident's clinical record. The absence of these records indicates a failure to adhere to the established protocols and agreements outlined in the facility's policy and the dialysis contract.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Harrisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchard Manor | 3.8 mi | ★★★★★ | 26 | 1 |
| Grove Manor | 4.6 mi | ★★★★★ | 19 | 0 |
| Quality Life Services - Grove City | 4.8 mi | ★★★★★ | 6 | 0 |
| Avalon Springs Care Center | 15 mi | ★★★★★ | 6 | 0 |
| Quality Life Services - Mercer | 15.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.