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
- 19
- 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
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
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