Inspection Reports for Autumn Lake Healthcare at Crystal Springs

The inspection was conducted to review facility documentation and staff interviews to assess compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be in compliance with all applicable Federal, State, and local Emergency Preparedness requirements based on documentation review and staff interviews.

An unannounced annual recertification/licensure, facility reported incident (FRI) and complaint survey was conducted at Autumn Lake Healthcare At Crystal Springs from 03/03/25 to 03/06/25.

The facility was found out of substantial compliance with multiple deficiencies including quality of care, care plan timing and revision, RN staffing coverage, grievance policy, PASARR coordination, food safety and storage, infection control, resident rights, accident hazards, and posting of nurse staffing information.

Complaint #33355 substantiated; other complaints and facility reportable incidents were substantiated or unsubstantiated as noted in the report.

The inspection was conducted as an investigation survey triggered by a complaint, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Autumn Lake Healthcare At Crystal Springs, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Investigation survey concluding on 03/06/2025 with substantial compliance found and plans of correction accepted in lieu of onsite revisit.

Routine inspection to assess compliance with NFPA fire safety codes, electrical system maintenance, and facility regulatory requirements.

The facility failed to maintain required semi-annual inspections and hydro testing of the cooking equipment range hood, semiannual visual inspections of smoke detectors, quarterly sprinkler system testing, fire drills at unexpected times, emergency power supply testing including fuel quality and load bank testing, and annual testing and maintenance of electrical patient-care equipment. These deficiencies could affect all residents, staff, and visitors.

An unannounced complaint investigation survey was conducted at Autumn Lake Healthcare at Crystal Springs from 11/25/24 to 11/26/24 based on complaints received.

The facility failed to follow physician's orders for weekly skin evaluations for four residents (#30, #76, #18, #75), failed to implement comprehensive care plans related to weekly skin evaluations for these residents, and failed to maintain complete and accurate medical records for residents #30, #75, and #18. Additionally, the facility failed to ensure physician review and documentation of pharmacist-reported medication irregularities for resident #35.

Complaints #29568 and #31430 were unsubstantiated. Complaint #33200 was substantiated with deficiencies cited at F684 and F756.

The visit was conducted as an investigation survey to review plans of correction and credible evidence related to previously cited deficient practices.

The facility, Autumn Lake Healthcare At Crystal Springs, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on the review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Investigation survey concluding on 02/22/24 reviewed plans of correction and credible evidence in lieu of onsite revisit; facility found in substantial compliance with previously cited deficient practices.

An unannounced annual recertification/licensure survey was conducted to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found out of substantial compliance with multiple deficiencies including failure to ensure residents' rights to dignity, incomplete nurse aide performance reviews and in-service training, inadequate care plan revisions, improper catheter and respiratory care, incomplete medical records, failure to maintain accurate staffing records, and environmental issues such as unclean shower rooms and inadequate bathroom temperatures.

Complaint #29725, #30858, and #29801 were substantiated; #30812 and #30121 were unsubstantiated.

The inspection was conducted as a routine regulatory survey to assess compliance with NFPA 101 fire safety standards and emergency preparedness requirements.

The facility was found deficient in multiple areas including hazardous area enclosures, interior wall and ceiling finishes, sprinkler system maintenance, portable fire extinguisher installation, fire drills, emergency preparedness plan review and update, and emergency preparedness testing. Deficiencies could potentially affect all residents, staff, and visitors.

An unannounced complaint investigation survey was conducted at Autumn Lake Healthcare At Crystal Springs on 09/13/23.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

The survey was complaint-related and the facility was found in substantial compliance; no further substantiation details provided.

The inspection was conducted as a complaint investigation survey concluding on 2023-06-08, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Autumn Lake Healthcare is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

The complaint investigation survey concluded on 2023-06-08, and the facility was found in substantial compliance with previously cited deficient practices.

The inspection was conducted as a complaint investigation survey concluding on May 17, 2023, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Autumn Lake Healthcare at Crystal Springs, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint investigation survey concluded on May 17, 2023; facility found in substantial compliance with previously cited deficient practices.

An unannounced complaint investigation survey was conducted at Autumn Lake Healthcare at Crystal Springs from 06/05/23 to 06/08/23 based on allegations of abuse and medication administration concerns.

The facility failed to timely administer insulin to three residents, resulting in delayed medication administration beyond the facility's policy. Additionally, the facility failed to report an allegation of verbal and physical abuse involving Resident #1 to the appropriate state agencies in a timely manner.

Complaint #28526 was substantiated with related deficiencies cited at F684 (timely insulin administration). Complaint #28528 was substantiated with related deficiencies cited at F609 (failure to report abuse). Resident #1 alleged a staff member ran over her toes with a wheelchair and scrubbed her back with a hard brush. The facility did not report this allegation to state agencies until the survey date despite investigation. The Nursing Home Administrator acknowledged the failure to report and stated the allegation was unsubstantiated but would be reported immediately.

An unannounced complaint investigation survey was conducted at Autumn Lake Healthcare at Crystal Springs from 05/15/23 to 05/17/23 based on complaints #28444 and #28342.

The facility was found deficient in implementing care plans related to fall interventions and respiratory care, and failed to complete neurological checks after unwitnessed falls for two residents. Deficiencies were substantiated for complaints #28444 and #28342.

Complaint #28444 was substantiated with related deficiencies cited at F656 and F684. Complaint #28342 was substantiated with unrelated deficiencies cited at F695.

The visit was conducted as a complaint investigation survey, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Autumn Lake Healthcare at Crystal Springs, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. The previously cited deficient practices were corrected as evidenced by the accepted plans of correction.

The complaint investigation survey concluded on 12/13/2022, and the facility was found to be in substantial compliance with previously cited deficiencies.

An unannounced complaint investigation survey was conducted at Autumn Lake Healthcare at Crystal Springs from December 12-13, 2022, triggered by complaint #27723.

The facility was found deficient in multiple areas including failure to maintain a safe environment (razors accessible in unlocked shower rooms), failure to prevent misappropriation of controlled substances, failure to conduct COVID-19 testing on exposed staff during an outbreak, failure to maintain accurate controlled substance records, and failure to provide proper transfer documentation when residents were sent to hospitals.

Complaint #27723 was substantiated with related deficiencies cited.

An unannounced complaint investigation and focused infection control survey was conducted at Autumn Lake Healthcare at Crystal Springs from September 21-22, 2022.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaint #27425 was unsubstantiated with no related or unrelated deficiencies cited. No citations related to infection control.

Complaint #27425 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and annual relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the regulatory requirements, with credible evidence accepted in lieu of an onsite revisit. The facility was in substantial compliance with previously cited deficient practices.

An unannounced annual recertification and annual relicensure survey was conducted at Autumn Lake Healthcare at Crystal Springs from July 5-13, 2022.

The facility was found deficient in multiple areas including resident rights, privacy, grievance handling, use of restraints, abuse reporting, care planning, quality of care, respiratory care, pharmacy services, medication management, dental services, food safety, medical record completeness, and COVID-19 vaccination compliance among staff.

The inspection was conducted to assess the facility's compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012, and to verify compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the NFPA 101 Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.

The inspection was conducted as a complaint investigation survey, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

The complaint investigation survey concluded on 03/08/2022, and the facility was found in substantial compliance with previously cited deficiencies.

An unannounced complaint survey was conducted at Autumn Lake Healthcare at Crystal Springs from 03/07/22 to 03/08/22 based on complaint #26505 which was substantiated with related deficiencies cited.

The facility failed to provide adequate Activities of Daily Living (ADL) care to dependent residents, specifically Resident #5 who did not receive scheduled personal hygiene services. Additionally, the facility had residents in incorrect rooms, including Resident #4 and Resident #12, which could lead to quality of care errors.

Complaint #26505 was substantiated with related deficiencies cited at F677 and an unrelated deficiency cited at F684.

An unannounced complaint investigation was conducted at Nella's Nursing Home on July 26-27, 2021.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.

Complaint #25165 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #25704 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced annual re-certification and annual re-licensure survey was conducted at Nella's Nursing Home from April 5-7, 2021.

The survey identified deficiencies related to inaccurate advanced directive documentation for one resident, failure to follow physician orders for blood glucose monitoring and sliding scale insulin for one resident, and failure to timely address pharmacy consultant recommendations regarding unnecessary medications for two residents.

Complaint #25281 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, Nella's Nursing Home, was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

An unannounced annual re-certification and annual re-licensure survey was conducted at Nella's Nursing Home from April 5-7, 2021.

The facility was found deficient in accurately formulating an advanced directive for one resident, failing to follow physician orders for blood glucose monitoring and sliding scale insulin for another resident, and failing to timely address pharmacist recommendations regarding unnecessary medications for two residents.

Complaint #25281 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2012, and applicable Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of the NFPA 101, Life Safety Code, 2012, and all applicable Emergency Preparedness requirements.

The inspection was conducted to assess the facility's compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012, and to verify compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and met all applicable Federal, State, and local Emergency Preparedness requirements.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on June 30-July 1, 2020.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and CMS and CDC recommended practices to prepare for COVID-19.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules.

The facility, Nella's Nursing Home, was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

An unannounced annual re-certification and annual re-licensure survey was conducted at the facility from 05/20/19 through 05/22/19 to assess compliance with federal regulations.

The facility was found deficient in multiple areas including failure to develop comprehensive person-centered care plans for oxygen therapy and catheter care, failure to provide care according to physician orders for oxygen therapy, inadequate accident hazard prevention, improper storage of medications, food safety violations, infection prevention and control deficiencies, and failure to maintain proper documentation and follow-up on physician orders and drug regimen reviews.

The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2012, and to verify compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, Nella's Nursing Home, was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

An unannounced annual re-certification and annual re-licensure survey was conducted at Nella's Nursing Home from July 16, 2018 through July 19, 2018.

The survey identified multiple deficiencies including failure to treat residents with dignity, failure to ensure call bells were within reach, unsafe storage of hazardous chemicals, food safety violations, ineffective quality assurance and infection control programs, and failure to implement an antibiotic stewardship program.

The inspection was conducted as an annual survey to assess compliance with federal and state regulations including fire alarm system maintenance, electrical system testing, and emergency preparedness.

The facility was found deficient in maintaining proper records for fire alarm system testing, incomplete documentation and testing of hospital-grade electrical receptacles, and failure to develop and maintain a comprehensive emergency preparedness plan reviewed and updated annually. These deficiencies could potentially affect all residents, staff, and visitors.

The document is a plan of correction related to a Quality Indicator and Licensure Survey for a nursing home, accepted in lieu of an onsite revisit.

The facility, Nella's Nursing Home, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted from 05/01/17 through 05/03/17 to assess compliance with regulatory requirements.

The facility was found deficient in implementing and monitoring care plan interventions related to nutritional status for residents #81 and #37, including failure to document and monitor nutritional supplement intake and meal consumption, resulting in unplanned weight loss and incomplete medical records.

The inspection was conducted to assess compliance with NFPA fire safety standards and building system requirements, including smoke barrier construction, building system risk assessments, electrical system maintenance, and staff training on medical gas equipment.

The facility was found deficient in maintaining smoke barriers with proper fire resistance, documenting risk assessments for building systems, performing required maintenance and testing of emergency electrical systems, and providing adequate training for personnel handling medical gases. These deficiencies could potentially affect all residents, staff, and visitors.

The document is a plan of correction related to a Quality Indicator and Licensure Survey for a nursing home, accepted in lieu of an onsite revisit.

The facility, Nella's Nursing Home, is in substantial compliance with 42 CFR Part 483 and state nursing home licensure rules, with previously cited deficient practices addressed through plans of correction.

An unannounced annual Quality Indicator Survey was conducted at Nella's Nursing Home from March 7, 2016 through March 16, 2016 to assess compliance with regulatory requirements.

The survey identified multiple deficiencies including failure to deposit resident funds in interest-bearing accounts, inadequate accommodations for resident needs, failure to conduct accurate comprehensive assessments, failure to protect residents from abuse, failure to maintain dignity and respect, failure to honor resident choices, failure to provide care per plan, unsafe environment hazards, unsanitary food service practices, infection control lapses, and incomplete clinical records.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.

The inspection was conducted as a complaint investigation, reviewing plans of correction and credible evidence in lieu of an onsite revisit for the complaint investigation concluding on 2015-09-03.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and with previously cited deficient practices.

Complaint Reference: 14081. The complaint investigation concluded on 2015-09-03 with the facility in substantial compliance.

An unannounced complaint survey was conducted from 08/31/15 through 09/03/15 at Nella's Nursing Home, Inc. Complaint #14081 was substantiated with a related deficiency cited.

The facility failed to promptly notify one of three residents' legal representatives when there was an accident involving injury, a need to significantly alter treatment, and/or a need for physician intervention. Resident #76 suffered an injury during an elopement and was discharged without timely notification to the responsible party.

Complaint #14081 was substantiated. The responsible party for Resident #76 was not notified until over six hours after the incident and discharge decision, despite the resident suffering injury and aggressive behavior during elopement.

The document is a plan of correction related to a Quality Indicator and Licensure Survey for a nursing home, accepted in lieu of an onsite revisit.

The facility, Nella's Nursing Home, is in substantial compliance with 42 CFR Part 483 and state nursing home licensure rules, with previously cited deficient practices addressed through plans of correction.

Unannounced annual Quality Indicator and Licensure Surveys were conducted at Nella's Nursing Home from February 11, 2015 to February 19, 2015 to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including housekeeping and maintenance services, employee background checks, comprehensive care planning, garbage disposal, medication labeling, infection control, and clinical record accuracy. Deficiencies involved unlabeled bedpans and wash basins, incomplete employee registry checks, failure to update care plans for residents with decline in ADLs, improper garbage containment, multi-dose medication vials dated incorrectly, lack of infection control policies for labeling and storage of equipment, and incomplete post-fall assessments.

The inspection was conducted as part of the annual survey to assess compliance with regulatory standards including life safety code and resident rights.

The facility was found to have deficiencies related to life safety code violations including the use of soiled linen receptacles exceeding allowed capacity in egress corridors and improper electrical wiring with multi-tap extensions powering multiple appliances. These issues were discussed with the facility maintenance director.

An unannounced complaint investigation was conducted from 08/18/14 to 08/20/14 at Nella's Nursing Home, Inc. for Complaint Reference 11700.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

The allegations were unsubstantiated.

This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection of Autumn Lake Healthcare at Crystal Springs.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2000.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.

The inspection was conducted as part of Quality Indicator and Licensure Surveys from 10/07/13 to 10/10/13 to assess compliance with care plan services and resident rights.

The facility failed to provide services in accordance with the care plan for two residents: Resident #2 was not wearing prescribed tubigrips during the day, and Resident #74 lacked evidence of an orthostatic hypotension assessment despite being at risk for falls.

The inspection was conducted as a complaint investigation based on complaint reference 13199 / 8665.

The complaint was found to be unsubstantiated with no citations issued.

Complaint reference 13199 / 8665 was investigated and found to be unsubstantiated with no citations.

The inspection was conducted as a complaint investigation referenced by complaint numbers 8496 and 13175.

The complaint was found to be unsubstantiated and no citations were issued.

Complaint Reference: 8496 / 13175. Unsubstantiated complaint record with no citations.

This document is a Plan of Correction submitted by the facility in response to cited deficiencies during a prior inspection.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was a routine Quality Indicator Survey conducted from 11/12/12 to 11/20/12, including off-hours review.

The facility was found deficient in multiple areas including failure to investigate and report abuse allegations, unsafe and unsanitary conditions of equipment and furniture, inaccurate resident assessments and care plans, failure to provide ordered nutritional supplements and dental care, medication management issues including exceeding acetaminophen dosage and delayed medication dose reduction, improper storage of medications and sterile supplies, and incomplete or inaccurate medical records.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.

The inspection was conducted as a complaint investigation based on complaints #11270 and #11303.

The complaints were investigated and found to be not substantiated. No tags or deficiencies were cited during this survey.

Complaints #11270 and #11303 were investigated and found to be not substantiated.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically focusing on the maintenance and testing of smoke detectors and the proper use of soiled linen receptacles in the facility.

The facility failed to maintain the fire alarm system in accordance with NFPA 72 due to lack of documentation of current or complete sensitivity testing of all smoke detectors. Additionally, the facility had soiled linen receptacles greater than 32 gallons located in the means of egress corridor that was not protected as a hazardous area.

Complaint investigation #11021 was conducted concurrently with the facility Medicaid certification resurvey and State licensure inspection due to allegations related to resident rights and room changes.

The facility failed to notify residents and their responsible parties of room changes for three residents (#78, #51, and #66), failed to maintain accurate and complete clinical records including care plan implementation for residents #12 and #72, failed to properly manage resident funds after death, failed to maintain sanitary conditions including housekeeping and infection control, and failed to ensure proper medication labeling and storage.

Complaint reference #11021 was unsubstantiated with no related deficiencies cited. The complaint investigation was conducted concurrently with Medicaid certification resurvey and State licensure inspection.

This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection of Autumn Lake Healthcare at Crystal Springs.

The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as a substantiated complaint investigation (reference #10207) regarding the facility's failure to accommodate resident preferences.

The facility failed to accommodate the bathing preferences of Resident #43, who preferred evening showers but was receiving morning showers, resulting in aggressive behavior and injuries. Additionally, the facility did not have a care plan or schedule to ensure individual bathing preferences were communicated or followed.

Complaint reference #10207 was substantiated with deficiencies cited related to failure to accommodate resident bathing preferences and failure to develop an appropriate care plan.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of the facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand.

The inspection was conducted in response to complaint reference #10151.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #10151 was investigated and found to be unsubstantiated with no deficiencies cited.

Complaint references #10097 and #10115 triggered this investigation, focusing on non-compliance with Medicaid certification requirements and State nursing home licensure rules.

The facility was found deficient in revising care plans for exit-seeking behavior, providing appropriate treatment for aggressive behaviors, maintaining infection control during dressing changes, and ensuring an adequate nurse call system for timely staff response. Specific residents (#52, #5, #46) were involved in these findings.

Complaint references #10097 and #10115 were unsubstantiated with unrelated deficiencies for non-compliance with Medicaid certification requirements and State nursing home licensure rule.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including fire protection ratings of smoke barrier doors, fire alarm system maintenance, and kitchen rangehood cleaning.

The facility failed to maintain all smoke barrier doors to a 20-minute fire resistance rating, had deficiencies in the fire alarm system's automatic phone dialer notification, and lacked documentation verifying that the kitchen rangehood was cleaned by a qualified company within the previous 12 months.

The inspection was conducted as an annual survey to assess compliance with federal regulations governing nursing facilities, including resident rights, care planning, abuse prevention, and record keeping.

The facility was found deficient in multiple areas including failure to convey resident funds upon death, failure to promptly resolve resident grievances, failure to investigate and report abuse allegations, failure to ensure new employees were checked against the Nurse Aide Abuse Registry, failure to revise care plans after significant changes in resident condition, failure to maintain a safe environment to prevent accidents, and failure to maintain complete and organized clinical records.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of Autumn Lake Healthcare at Crystal Springs.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, privacy, staff treatment, accident prevention, and advance directives.

The facility was found deficient in maintaining resident privacy, ensuring thorough investigation and reporting of incidents and injuries, and implementing care plan interventions to prevent accidents. Specific deficiencies included failure to maintain privacy curtains and doors closed during care, inadequate investigation and reporting of injuries of unknown origin, and failure to follow care plan instructions for safe resident transfers.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to resident rights and facility safety.

The facility was found deficient in maintaining all means of egress readily accessible, improperly storing trash receptacles exceeding 32 gallons outside of hazardous areas, and failing to provide battery-powered emergency lighting in the generator transfer switch room.

The inspection was conducted due to complaints received from residents and family members alleging abuse, neglect, misappropriation of resident property, and other care concerns.

The facility failed to report eight of thirteen complaints involving abuse, neglect, and misappropriation to State agencies. Deficiencies were found in staff treatment of residents, dignity, quality of care including incontinence care and dental assessments, accident prevention during mechanical lift transfers, and medication management including failure to attempt gradual dose reduction of sedative medication.

The complaint investigation revealed that eight of thirteen complaints alleging abuse, neglect, and misappropriation of resident property were not reported to State agencies as required by law. Specific complaints included poor hygiene, missing personal items, rude staff behavior, and failure to assist residents properly.

The inspection was conducted in response to complaint references #2-8084 and #2-8096.

The complaint records were found to be unsubstantiated with no deficiencies cited.

Complaint references #2-8084 and #2-8096 were investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-8039.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-8039 was unsubstantiated with no deficiencies cited.

The inspection was conducted in response to complaint reference #2-7261 to investigate the allegations made.

The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-7261 was unsubstantiated with no deficiencies cited.

The document is a plan of correction submitted in response to a previous inspection, specifically a paper revisit.

The document references a deficiency related to informing residents of their rights and facility rules, but does not provide detailed findings beyond noting the paper revisit status.

The inspection was conducted concurrently with the facility's annual State licensure and Federal Medicaid certification inspections, including complaint investigations.

The facility was found to have multiple deficiencies including failure to consult two physicians when a resident regained decision-making capacity, failure to maintain resident dignity by awakening residents early for lab draws, inaccurate documentation of residents' physical conditions, incomplete care plans, inadequate evaluation of PRN medication effectiveness, duplicate narcotic orders, and unsanitary food preparation conditions.

Complaint reference #2-7002 was substantiated with deficiencies cited. Complaint reference #2-7034 was unsubstantiated with no related deficiencies cited.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

The inspection was conducted as a complaint investigation (reference #2-6242) regarding concerns about the facility's practices related to photographing deceased residents and other regulatory compliance issues.

The facility was found to have failed to maintain residents' dignity and respect by taking nude photographs of deceased residents without proper consent or family awareness. Additionally, the facility failed to assure that meals met nutritional needs and that menus were followed, affecting multiple residents.

Complaint reference #2-6242 was substantiated with findings unrelated to federal certification and state licensure deficiencies. The complaint focused on the facility's practice of photographing deceased residents without proper consent and the emotional distress caused to families.

The inspection was conducted to assess compliance with regulations regarding the protection of resident funds, specifically the requirement to establish interest-bearing accounts for residents whose funds exceed fifty dollars.

The facility was found not in compliance for failing to institute interest-bearing accounts for residents with funds exceeding fifty dollars. Eighteen resident accounts were found deposited in a non-interest bearing checking account. The facility began corrective action by contacting a bank representative to establish individual interest-bearing accounts for twenty residents with funds exceeding fifty dollars, totaling $7,488.00.

This document is a plan of correction submitted in response to deficiencies identified during a prior inspection.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand.

Annual inspection of Autumn Lake Healthcare at Crystal Springs nursing facility to assess compliance with federal regulations including resident rights, care, safety, and facility operations.

The facility was found deficient in multiple areas including failure to properly exercise resident rights, inadequate notification of rule changes, improper handling of resident funds, incomplete clinical records, failure to conduct comprehensive assessments and care planning, medication management issues, food preparation and sanitation problems, inadequate staff training, and failure to maintain proper documentation and postings.

The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the installation and maintenance of the automatic sprinkler system throughout the facility.

The facility has an automatic sprinkler system; however, it was found that not all portions of the facility are provided sprinkler coverage. Specifically, no sprinkler heads were located within or serving the South Handicap Toilet and the North Handicap Toilet near the Central Bathing Area.

This document is a plan of correction related to a paper revisit survey conducted at the facility.

The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally, but does not provide detailed findings within this excerpt.

Complaint investigation related to substantiated complaints with state licensure and federal certification deficiencies cited.

The facility failed to afford a resident (#79) the right to sign admission paperwork despite having capacity, failed to inform the resident of significant health status changes, failed to plan and assist with transfer to an assisted living facility, failed to report and investigate an allegation of neglect, failed to accurately assess and document the resident's discharge potential, and failed to develop an individualized care plan to facilitate the resident's discharge goals.

Complaint reference #2-5297 was substantiated with state licensure and federal certification deficiencies cited. The complaint involved issues with resident rights, notification of health status changes, discharge planning, neglect allegation reporting and investigation, and care planning for resident #79.

The inspection was conducted in response to complaint reference #2-5097 to investigate the allegations made.

The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-5097 was unsubstantiated with no deficiencies cited.

Paper revisit to review and verify corrections related to previously cited deficiencies.

The document is a plan of correction related to a previously cited deficiency regarding the facility's obligation to inform residents of their rights and services in writing and orally. No new deficiencies or findings are detailed.

Routine inspection survey conducted to assess compliance with federal regulations related to resident rights, quality of life, infection control, staff qualifications, dietary services, resident assessments, and physical environment.

The facility was found deficient in multiple areas including failure to ensure resident rights and privacy, inadequate infection control practices, incomplete resident assessments, failure to conduct statewide criminal background checks on employees, poor sanitary conditions in the kitchen, failure to provide timely call bell responses, and lack of quality control for glucometer testing.

The inspection was conducted as a routine survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements at Autumn Lake Healthcare at Crystal Springs.

The facility was found to have multiple deficiencies related to life safety code standards, including corridor doors held open with wedges, failure to maintain and inspect the range hood extinguishing system, improper storage of soiled linen receptacles, and unsecured oxygen storage rooms.

The inspection was conducted in response to complaint references #2-4237 and #2-4238.

The complaint records were found to be unsubstantiated with no deficiencies cited.

Complaint references #2-4237 and #2-4238 were investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted as a re-inspection to verify correction of previously cited deficiencies related to resident rights postings and pharmacy services.

The facility was found deficient in prominently displaying current information about Medicare and Medicaid benefits, including ombudsman contact details, and in pharmacy services documentation where the pharmacist did not note when no irregularities were found in drug regimen reviews.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations governing nursing facilities, including resident rights, assessments, care planning, medication management, dietary services, and pharmacy services.

The facility was found deficient in multiple areas including failure to accurately complete resident assessments, incomplete care plans, inappropriate medication dosing and duration, failure to follow dietary menus, and inadequate pharmacist reporting of medication irregularities. Several residents were identified with specific deficiencies related to these areas.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations for nursing facilities, including resident care, environment, medication administration, and infection control.

The facility was found deficient in multiple areas including failure to provide clean linens, inadequate comprehensive care plans for residents, improper medication administration practices, failure to implement ordered treatments, unsafe physical environment, infection control breaches, and poor maintenance of clinical records.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically focusing on the maintenance and inspection of the automatic sprinkler system and the range hood extinguishing system.

The facility failed to have the sprinkler system inspected and tested quarterly as required by NFPA 25, with a lapse of approximately five months between inspections. Additionally, the range hood extinguishing system was not maintained and inspected semiannually as required by NFPA 96, with the last service tag expired since 11/30/03.

The inspection was conducted as a complaint investigation related to complaint reference #2-3227.

The complaint was substantiated; however, no deficiencies were cited during the investigation.

Complaint reference #2-3227 is a substantiated complaint record with no deficiencies cited.

The survey team conducted a revisit survey to verify compliance with previous citations.

The facility was found to be in compliance with all previous citations and no new deficiencies were written as a result of the revisit survey.

The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 1985.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 1985.

The inspection was conducted as part of the annual survey to assess compliance with federal regulations regarding resident rights, quality of care, dietary services, clinical record maintenance, and other regulatory requirements.

The facility was found deficient in several areas including failure to provide medically-related social services for discharge planning, inadequate pain management for a resident with a fractured femur, failure to provide palatable and properly temperature-controlled food, and incomplete clinical documentation regarding PRN medication administration.

The inspection was conducted to evaluate the facility's compliance with NFPA 101 Life Safety Code standards, including fire drills, fire alarm system testing, sprinkler system coverage and maintenance, and fire extinguishing system inspections.

The facility failed to conduct fire drills on each shift quarterly, did not test the fire alarm system monthly, lacked sprinkler coverage in janitor closets, did not inspect and test the sprinkler system quarterly as required, and failed to perform monthly inspections of the range hood wet chemical extinguishing system for November and December 2001.

The inspection was conducted as a standard annual survey to assess compliance with federal regulations governing nursing facilities.

The facility was found deficient in several areas including failure to ensure residents received mail on weekends, inaccurate resident assessments particularly regarding pressure ulcers, lack of comprehensive care plans for identified behaviors, failure to ensure timely physician visits, and lack of contractual arrangements with dialysis providers for residents receiving renal dialysis.

The inspection was an annual survey of Autumn Lake Healthcare at Crystal Springs to assess compliance with federal regulations regarding resident rights, care, and facility operations.

The facility was found deficient in multiple areas including failure to notify legal representatives of significant resident condition changes, improper use of chemical restraints, inadequate social services, incomplete resident assessments, failure to complete significant change assessments timely, failure to notify physicians of elevated blood sugars, inadequate quality of care related to pressure sore treatment and nutritional status, improper maintenance of oxygen equipment, unnecessary drug use without adequate monitoring, incomplete physician documentation, failure of pharmacist to report irregularities properly, and poor clinical record maintenance.

The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code standards, specifically regarding fire rated and smoke resistant construction in the facility.

The facility was found deficient in maintaining one hour fire rated and smoke resistant construction, including unsealed recessed ceiling light fixtures compromising fire barriers and kitchen corridor doors lacking frame stops and positive latching, compromising fire and smoke separation.

The inspection was conducted based on a review of facility documentation, staff interviews, observations, and performance testing to determine compliance with the provisions of 483.70 Physical Environment.

The facility was found to be in compliance with the provisions of 483.70 Physical Environment.

The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code standards, specifically evaluating fire rated and smoke resistant construction and separation of hazardous areas within the facility.

The facility was found deficient in maintaining one hour fire rated and smoke resistant construction due to unsealed recessed ceiling light fixtures compromising the fire barrier. Additionally, fire rated and smoke resistant separation of hazardous areas was compromised by kitchen corridor doors lacking frame stops and positive latching, which affects the required fire and smoke resistance between the kitchen and emergency egress corridor.

Initial inspection of a new construction facility to determine compliance with physical environment provisions.

Based on review of facility documentation, observations, and performance testing, the facility was found to be in compliance with the provisions of 483.70 Physical Environment.

Initial inspection of a new construction facility to determine compliance with applicable regulations and codes.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 1985 (New).

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with the provisions of 483.70 Physical Environment.

The facility was found to be in compliance with the provisions of 483.70 Physical Environment based on the review and evaluation conducted during the inspection.

The inspection was conducted to assess compliance with NFPA 101, Life Safety Code, focusing on the facility's construction standards and fire safety across multiple zones.

All eleven zones inspected passed the FSES inspection for life safety, indicating the facility met the minimum construction standards required for fire safety.

The inspection was conducted as an annual survey of Nella's Nursing Home to assess compliance with Federal health regulations.

Based on the survey conducted from April 3-6, 2000, Nella's Nursing Home was found to be in compliance with all Federal health regulations.

The inspection was conducted in response to complaint #20028 regarding nursing services and physician delegation practices at the facility.

The facility failed to ensure a registered nurse was on duty for at least eight consecutive hours seven days a week, and failed to ensure that a physician did not delegate tasks prohibited by regulations or state law. One sampled resident was affected by improper delegation to a physician assistant without proper documentation.

Complaint #20028 triggered the investigation. The complaint involved nursing services and physician delegation issues. Substantiation status is not explicitly stated.