Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Elkins
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nella's At Autumn Lake Healthcare | 0.1 mi | ★★★★★ | 4 | 0 |
| Elkins Rehabilitation & Care Center | 4.7 mi | ★★★★★ | 13 | 0 |
| Tygart Valley Health & Rehabilitation | 6.6 mi | ★★★★★ | 12 | 0 |
| Mansfield Place | 16.7 mi | ★★★★★ | 0 | 0 |
| Holbrook Healthcare Center | 18 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.