Autumn Lake Healthcare at Spa Creek

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF908Aug 6, 2025

  Based on observations and interviews it was determined that the facility failed to ensure equipment was operational. This was found to be evident for 1 out of 1 observation for the door alarm operating system during the recertification survey.The findings include: During a facility tour conducted on 08/01/25 at 6:30 AM, this Surveyor and the Maintenance Director (MD) opened an exit door located in the first-floor stairwell due to a concern of a recent elopement. The MD explained that only authorized personnel are allowed to use the stairwell door. If an authorized personnel inputs the code into the pin pad then an audible alarm will not sound at the first-floor nursing station. […]

• No harm, potential for more than minimal, patternF656Aug 6, 2025

  Based on observation, record reviews and interviews, it was determined that the facility failed to develop/implement care plans for Residents. This was found to be evident for 5 (Resident # 16, #8, #60, #107, and #82) out of 25 Residents reviewed for care plans during the recertification survey. The findings include: 1) A care plan, as defined by CMS (Centers for Medicare & Medicaid Services), is a formal document outlining a resident's medical and personal care needs, treatments, and preferences within a nursing home or other care setting. It serves as a communication tool for the interdisciplinary team to coordinate services and ensure the resident's highest practicable physical, mental, and psychosocial well-being. […]

• No harm, potential for more than minimal, patternF658Aug 6, 2025

  Based on observations, interviews and record reviews it was determined that the facility failed to ensure staff provided services that met professional standards of practice. This was found to be evident for 5 (Resident #55, #131, #81, #142, and #96) out of 5 Residents reviewed for Services Meet Professional Standards of Practice during the recertification survey.The findings include: 1) During a medication administration observation conducted on 07/31/25 at 7:31 AM, this Surveyor observed License Practice Nurse (LPN) #4 administer Resident #55’s morning medications. […]

• No harm, potential for more than minimal, patternF759Aug 6, 2025

  Based on observations, interviews and record reviews it was determined that the facility failed to ensure medications were administered with a 5% or less error rate. This was found to be evident for 12 errors out of 31 medication administration opportunities that resulted in an error rate of 38.71% during the recertification survey. The findings include: 1) During a medication administration observation conducted on 07/31/25 at 7:31 AM, this Surveyor observed License Practice Nurse (LPN) #4 administer Resident #55's morning medications. […]

• No harm, potential for more than minimal, patternF761Aug 6, 2025

  Based on observations and interviews it was determined that the facility failed to ensure that 1) the medication refrigerator was used to store only medications and 2) medications were stored properly in the medication carts. This was found to be evident for 1 (1st floor medication refrigerator) out of 2 medication refrigerators and 3 out of 4 medication carts observed for medication storage during the recertification survey. The findings include: 1) An observation was conducted on 08/05/25 at 6:06 AM in the first-floor storage room. […]