Autumn Lake Healthcare at Crystal Springs

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at Crystal Springs, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF726Feb 22, 2024

  Based on record review and staff interview, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population. This was true for five (5) of five (5) staff members reviewed for competencies. Facility census: 59. a) Nurse Aide (NA) #100 At approximately 5:00 PM on 02/21/24, a record review was conducted for the facility's staffing. During that review, it was determined NA #100 had not completed any competencies. […]

• No harm, potential for more than minimal, widespreadF880Feb 22, 2024

  Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections. The facility failed to provide appropriate infection surveillance, hand hygiene and catheter care. This failed practice had the potential to affect every resident currently residing in the facility. Resident Identifiers: #43 and #44. Facility census: 59. Findings included: a) Infection Surveillance Record review of the facility's Infection control practices found the facility was unable to provide the required infection surveillance documentation of communicable illnesses. […]

• No harm, potential for more than minimal, patternF584Jul 14, 2026

  Based on policy review, staff interview and observation, the facility failed to maintain a clean, comfortable and home-like environment regarding odors in the facility. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 74. Findings included: The facility's policy and procedure for Safe and Homelike Environment stated, 9.a. Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to the Housekeeping Department. On 06/29/26 at 11:30 AM upon entering the facility, the Survey Team identified a strong urine-like odor. On 06/29/26 at approximately 12:15 PM, both dining rooms had a strong urine-like odor. […]

• No harm, potential for more than minimal, patternF585Mar 6, 2025

  Based on observation and interviews, the facility failed to established a grievance policy that meets essential requirements. Specifically, it failed to: Notify residents individually or provide clear postings throughout the facility about their right to file a grievance. The facility did not provide easy access to grievance forms. They facility did not notify residents of the right to file a grievance anonymously. Additionally, the facility did not provide easily accessible and clearly presented contact information for independent entities where grievances can be filed, such as the appropriate state agency, Quality Improvement Organization, State Survey Agency, and State Long-Term Care Ombudsman programs. […]

• No harm, potential for more than minimal, patternF684Mar 6, 2025

  Based on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Resident #68's nebulizer treatment was left running for 20 minutes longer than it should have been. A resident was receiving oxygen at a rate that was not prescribed. Resident #22 did not receive blood sugar monitoring as required by physician order. Resident #28 was identified as a fall risk and had an order for their bed to be in the lowest posiotion did not have their bed in that position. Resident #85 had a seizure disorder and an intervention for padded side rails did not have padded side rails in place. Resident #8, #68, #22, #28, and #28. […]