Autumn Lake Healthcare Crystal Springs: Infection Control Failures - WV
Federal inspectors documented the lapse on October 21, 2025, during a complaint inspection at the 93-bed facility in Elkins.
The resident, identified in inspection records only as Resident #62, had an indwelling urinary catheter and an open wound in the right groin area. Because of those conditions, the facility had placed the resident on Enhanced Barrier Precautions, a protocol that requires staff to wear both gloves and a gown when performing certain hands-on care. The precautions exist specifically to reduce the spread of resistant organisms and other infections between residents and staff.
Licensed Practical Nurse #24 wore gloves. She did not wear a gown.
When an inspector asked whether Resident #62 was on Enhanced Barrier Precautions, the nurse looked puzzled before answering. "Yes," she said, "both residents are on EBP." She did not then attempt to put a gown on. She continued the care without one.
The gown is not a formality. For a resident with an open wound in the groin undergoing catheter care, the protocol is designed to keep contaminated material from transferring to a caregiver's clothing and then to the next room, the next resident, the next surface. A nurse who knows a resident is on Enhanced Barrier Precautions and proceeds without a gown anyway has made a choice, whether through habit, inattention, or a belief that the step doesn't matter much.
The inspection report does not say which it was. It records only what happened.
At the end of the care, LPN #24 had no plastic bag available to collect the soiled washcloths and towels she had used. She dropped them on the floor. An inspector provided a plastic bag at that point. The linens went in. The care was over.
The contaminated linens on the floor represent a second, separate breakdown. Soiled materials from wound and catheter care carry the same organisms the gown was meant to contain. Dropping them on the floor, even briefly, creates a surface contact risk in a room where a vulnerable resident lives.
Inspectors cited the facility under F0880, the federal requirement that nursing homes provide and implement an infection prevention and control program. The violation was tagged at a harm level of minimal harm or potential for actual harm, and inspectors noted that few residents were affected. The inspection reviewed one resident for this type of care. That resident was Resident #62. The lapse was found in the one case they looked at.
The facility's own policy was reviewed as part of the inspection. The report does not describe what that policy said, only that the nurse's practice did not follow it.
Autumn Lake Healthcare at Crystal Springs is a for-profit facility licensed for 93 beds. The inspection was a complaint survey, meaning someone had raised a concern before inspectors arrived.
What the report leaves open is how often care like this happens when no one is watching. LPN #24's puzzled expression when asked about the precautions, followed by an acknowledgment that yes, the resident was on EBP, followed by no attempt to correct course, suggests a gap between what staff know in the abstract and what they do in the room. That gap is where infections move.
Resident #62, with an open wound and a catheter, sat at the center of that gap on a Tuesday morning in October.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Crystal Springs from 2025-10-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS in ELKINS, WV was cited for violations during a health inspection on October 23, 2025.
Federal inspectors documented the lapse on October 21, 2025, during a complaint inspection at the 93-bed facility in Elkins.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.