Elkins, WV

Autumn Lake Healthcare At Crystal Springs

1-star overall rating with 2-star inspections with 18 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

200 Whitman Avenue, Elkins, WV

(304) 636-2033

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Autumn Lake Healthcare

Operator or chain grouping

Approved since

2021-12-23

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

60 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.30

Registered nurse staffing · state 0.71 · national 0.68

LPN hours / resident day

0.99

Licensed practical nurse staffing · state 0.92 · national 0.87

Aide hours / resident day

2.14

Nurse aide staffing · state 2.07 · national 2.35

Total nurse hours

3.44

All reported nurse hours · state 3.69 · national 3.89

Licensed hours

1.30

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

2.89

Weekend nurse staffing · state 3.18 · national 3.43

Weekend RN hours

0.19

Weekend registered nurse coverage · state 0.39 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.28

CMS adjusted RN staffing hours

Adjusted total hours

3.11

CMS adjusted total nurse staffing hours

Case-mix index

1.51

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

69%

Annual nurse turnover · state 43% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,224

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

17.63

Composite VBP score used to determine payment impact.

Payment multiplier

0.9818

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

2.86

Performance 6.98% · Measure score 2.86 · Achievement 2.86 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

Performance 76.14% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

2.43

Baseline 4.16 hours · Performance 3.77 hours · Measure score 2.43 · Achievement 2.43 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.67%	10.72% 1.1 pts better	No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 6.32%
Discharge to community	41.65%	50.57% 8.9 pts worse	No Different than the National Rate · Eligible stays 41 · Observed rate 26.83% · Lower 95% interval 28.7%
Medicare spending per beneficiary	1.06	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 32 · Denominator 32
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 32
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	6.25%	2.29% 4 pts worse	Numerator 2 · Denominator 32 · Adjusted rate 3.59%
Healthcare-associated infections requiring hospitalization	6.98%	7.12% 0.1 pts better	No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 4.1%
Staff COVID-19 vaccination coverage	2.06%	8.2% 6.1 pts worse	Numerator 2 · Denominator 97
Staff flu vaccination coverage	5.88%	42% 36.1 pts worse	Numerator 7 · Denominator 119
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.8	1.9 1.9 pts worse	1.9 1.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.6 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	5.8	1.9 3.9 pts worse	1.8 4 pts worse	Long Stay · 20240701-20250630 · Adjusted 5.8 · Observed 5.6 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.3%	96.7% 2.6 pts better	93.4% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.8%	97.6% 3.8 pts worse	95.5% 1.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8%
Percentage of long-stay residents experiencing one or more falls with major injury	5.2%	4.5% 0.7 pts worse	3.3% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 5.3% · Q3 4.1% · Q4 5.1% · 4Q avg 5.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	72.2%	6.8% 65.4 pts worse	11.4% 60.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 70.8% · Q3 64.4% · Q4 66.7% · 4Q avg 72.2%
Percentage of long-stay residents who lose too much weight	8.9%	6.6% 2.3 pts worse	5.4% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 12.9% · Q3 10.1% · Q4 6.9% · 4Q avg 8.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	25.5%	27.0% 1.5 pts better	19.6% 5.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 23.9% · Q3 23.2% · Q4 27.8% · 4Q avg 25.5%
Percentage of long-stay residents who received an antipsychotic medication	52.7%	15.5% 37.2 pts worse	16.7% 36 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 47.9% · Q2 53.3% · Q3 52.3% · Q4 57.8% · 4Q avg 52.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	13.3%	19.5% 6.2 pts better	16.3% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 4.2% · Q3 5.9% · Q4 14.8% · 4Q avg 13.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.8%	17.6% 3.8 pts better	14.9% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 9.0% · Q3 4.8% · Q4 10.6% · 4Q avg 13.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.5% 0.4 pts worse	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.3%	1.8% 1.5 pts worse	1.7% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.7% · Q3 2.7% · Q4 3.8% · 4Q avg 3.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.9%	22.4% 3.5 pts better	19.8% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 23.8% · Q3 18.7% · Q4 15.4% · 4Q avg 18.9%
Percentage of long-stay residents with pressure ulcers	6.3%	4.7% 1.6 pts worse	5.1% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 5.9% · Q3 3.8% · Q4 6.7% · 4Q avg 6.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	78.7%	78.8% 0.1 pts worse	81.7% 3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 75.8% · Q2 75.8% · Q3 84.6% · Q4 77.4% · 4Q avg 78.7%
Percentage of short-stay residents who had an outpatient emergency department visit	37.1%	12.4% 24.7 pts worse	12.0% 25.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 37.1% · Observed 42.9% · Expected 12.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.1% 1.1 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	87.9%	79.4% 8.5 pts better	79.7% 8.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 87.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.3%	23.0% 3.3 pts worse	23.9% 2.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 31.4% · Expected 28.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-06 · Fire 2025-03-06

18 health deficiencies

Top issue: Resident Rights (5 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-02-22 · Fire 2024-02-22

29 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

7 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 3 Health 2022-07-13 · Fire 2022-07-13

29 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-06

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-04-07

F · Potential for more than minimal harm 2025-03-06

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-04-07

F · Potential for more than minimal harm 2025-03-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-04-07

F · Potential for more than minimal harm 2025-03-06

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-04-07

F · Potential for more than minimal harm 2025-03-06

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-04-07

C · Minimal harm 2025-03-06

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-04-07

F · Potential for more than minimal harm 2024-02-22

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-03-18

F · Potential for more than minimal harm 2024-02-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-18

D · Potential for more than minimal harm 2024-02-22

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2024-03-18

C · Minimal harm 2024-02-22

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-03-18

C · Minimal harm 2024-02-22

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-03-18

C · Minimal harm 2024-02-22

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-03-18

C · Minimal harm 2024-02-22

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-03-18

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-30

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2026-01-15

D · Potential for more than minimal harm 2025-10-23

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-12-05

D · Potential for more than minimal harm 2025-10-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-05

E · Potential for more than minimal harm 2025-03-06

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-05-02

E · Potential for more than minimal harm 2025-03-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-05-02

E · Potential for more than minimal harm 2025-03-06

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-05-02

E · Potential for more than minimal harm 2025-03-06

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-05-02

E · Potential for more than minimal harm 2025-03-06

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-05-02

E · Potential for more than minimal harm 2025-03-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-03-06

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-03-06

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-03-06

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-03-06

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-03-06

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-03-06

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-03-06

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-03-06

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-03-06

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-05-02

E · Potential for more than minimal harm 2024-11-26

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-01-06

E · Potential for more than minimal harm 2024-11-26

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-01-06

E · Potential for more than minimal harm 2024-11-26

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-01-06

D · Potential for more than minimal harm 2024-11-26

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2024-06-24

D · Potential for more than minimal harm 2024-11-26

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-01-06

F · Potential for more than minimal harm 2024-02-22

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2024-04-15

F · Potential for more than minimal harm 2024-02-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F572 · Resident Rights Deficiencies

Health

Give residents a notice of rights, rules, services and charges.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F851 · Administration Deficiencies

Health

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected 2024-04-15

E · Potential for more than minimal harm 2024-02-22

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-02-22

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-02-22

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-02-22

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-02-22

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-02-22

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-02-22

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-02-22

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-04-15

E · Potential for more than minimal harm 2023-06-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-08-05

D · Potential for more than minimal harm 2023-06-08

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-08-05

D · Potential for more than minimal harm 2023-05-17

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-17

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-06-23

E · Potential for more than minimal harm 2022-07-13

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2022-08-08

E · Potential for more than minimal harm 2022-07-13

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2022-08-08

E · Potential for more than minimal harm 2022-07-13

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2022-08-08

E · Potential for more than minimal harm 2022-07-13

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2022-08-08

E · Potential for more than minimal harm 2022-07-13

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-08-08

E · Potential for more than minimal harm 2022-07-13

F761 · Pharmacy Service Deficiencies

Health

Corrected 2022-08-08

E · Potential for more than minimal harm 2022-07-13

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2022-08-08