Nella's At Autumn Lake Healthcare

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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.

Based on observation, staff interview, resident interview and policy review the facility failed to provide a safe, clean, comfortable, homelike environment. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the complaint survey.

Resident identifiers #73, and #74. Facility census 96. Findings include:a) Water temperature in A Wing shower roomDuring an interview on 12/29/25 at 2:45 PM, Resident #73 who has a Brief Interview for Mental Status (BIMS) of 14 and stated, The showers are not hot, they are luke warm, Sometimes I will just do a bed bath because I know it will be warmer. The problem is, the crap is old.During an interview on 12/29/25 at 3:00 PM Resident #74 who has a BIMS score of 15 said that the showers are not very warm at all. The showers seem to be warmer if its earlier in the day. During an interview and observation on 12/29/25 at 3:10 PM, the Maintenance Supervisor (MS) took the temperature of the shower stall water in shower room (1) one on A wing. The shower stall water ran for approximately (7) seven minutes, in which

the temperature only reached 97.4 degrees Fahrenheit. The MS stated, We try to keep it between 105 and 110 degrees. The MS further confirmed that the water was not warm enough for a comfortable shower. b) Cleanliness of A wing shower roomsAn observation on 12/29/25 at 12:30PM of A wing shower room (1) one revealed approximately 20 wash rags stacked on the sharps container, 15 bottles of shampoo, conditioner, lotions and powders in the floor behind the shower room door along with a chair with four (4) towels and ten (10) washrags stacked in it.Further observation of A- hall shower room (2) two revealed approximately 25 wash rags stacked on the sharp container, two (2) towels and four (4) washrags on a chair behind the shower room door, a blue rag that was wet hanging in the shower stall and two (2) towels that appeared dirty in the floor.During an interview and observation on 12/29/25 at 12:45 PM, the Administrator confirmed the dirty towels, wash rags and bottles should not be in the shower rooms.c) Policy reviewA review on 12/30/25 at 10:00 AM, of the policy titled Storage and Management of Personal Hygiene Products, revealed under procedure (1) as follows:Personal hygiene products, including but not limited to soaps, shampoos, lotions and razors should be stored in individual resident rooms or designated personal storage areas to ensure that they are not accessible to other residents. These areas should be clean, dry and secure, preventing the potential for items to be tampered with or cross-contaminated.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nella's at Autumn Lake Healthcare

499 Ferguson Road Elkins, WV 26241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Based on interview and record review, the facility failed to employ a Certified Dietary Manager with appropriate credentials. The facility also failed to ensure that the Nutrition Services Staff had the County / State specified certification for safe handling of food. This deficient practice had the potential to affect all residents receiving meals in the facility. Facility Census: 96.Findings included:During an interview, on 12/29/25 at 12:35 PM, the surveyor asked Food Service Manager (FSM) #61 if he was a Certified Dietary Manager (CDM), and he stated, No I am not. The surveyor asked if they had a full-time Registered Dietician (RD) on staff, and he said No. During an interview, on 12/29/25 at 1:10 PM, the Administrator and the Director of Nursing (DON) indicated the facility did not have a full-time registered dietitian in the building.

She comes to facility once per week and is available remotely as needed.On 12/29/25 at 1:00 PM this surveyor asked FSM #61 for a copy of the staffing policy. He said that the staff belong to the facility and he was contracted through Healthcare Services Group (HCSG). I asked him to provide me with one from HCSG for himself. The surveyor went back at 2:25 PM to ask again for the staffing policy for the FSM and

he stated that his supervisor, the District Manager (DM) for HCSG stated the state surveyor could contact HCSG Human Resources (HR) if they wanted a copy of the policy. The surveyor called the phone number provided at 2:39 PM and left a voicemail asking for the policy.On 12/29/25 at 1:01 PM the surveyor asked FSM #61 for a copy of the Food Handler Certificates for the 10 employees in the department that have been employed for longer than 30 days. At 1:55 PM FSM brought the survey team a copy of three (3) of the 10 employees food handler certificates. FSM stated, That is all I have and the facilities HR department takes care of these.On 12/29/25 at 2:15 PM this surveyor spoke to HR #78 about the seven (7) missing food handler certificates and she said, They should be in the kitchen, and the previous FSM took care of this, and she will look for them and get back to me.On 12/30/25 at 8:45 AM this surveyor spoke to HR #78 about the missing food handler certificates. She said that she had found five (5) out of the ten. The surveyor told her that the FSM only gave copies of three (3) out of ten.As of 12/31/25 at 4:56 PM no one from the HCSG HR department has called or emailed this surveyor about the professional staffing policy.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nella's at Autumn Lake Healthcare

499 Ferguson Road Elkins, WV 26241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to maintain the equipment in safe and clean operating condition. This practice had the potential to affect all of the residents at the facility. Facility census: 96.Findings included:a) During a walkthrough of the kitchen on 12/29/25 at 12:40 PM there were multiple cases of disposable utensils, plates and cups sitting directly on the floor. The surveyor asked Food Service Manager (FSM) #61 if those items are allowed to be sitting directly on the floor, and he said Yes, because they are in boxes and are individually wrapped.There was one (1) bag of opened breadcrumbs in the dry storage room that were not sealed correctly and was not labeled or dated correctly. The FSM acknowledged that they should have been stored and dated properly and will fix it.There were two (2) full size sheet pans of turkey stock located in the walk-in refrigerator with a made date of 12/19/25. There was no use by date on either one. The FSM stated that they should have been thrown out

this past weekend.There was one (1) bag of opened parmesan cheese that was sealed correctly but did not have an open or a use by date located in the walk-in refrigerator. The FSM acknowledged it should have had those dates written on it per their policy.One (1) steam table pan of Gelatin was not covered correctly and was dated 12/20/25 without an use by date. The FSM acknowledged that there was a tear in the plastic film covering the gelatin and there was no use by date. He also acknowledged that the gelatin should have been thrown away by 12/27/25.There was some sliced bologna in a sandwich bag without a label or date located in the walk-in refrigerator. The FSM threw it away.The mixer was not covered while not in use. The surveyor asked the FSM if it should be covered while not in use and he stated, Some places do and some places don't.There was ice buildup in the walk-in freezer. The FSM stated that maintenance is aware.The two (2) door reach in refrigerator had debris and liquid spills. The FSM stated he did not have a equipment cleaning schedule, but was working on one.Two (2) ovens were soiled with debris on the inside and needed to be cleaned. One (1) oven rack was sitting directly on the floor. I asked the FSM if it was allowed to sit directly on the floor and he said they usually place it on top of the oven, not on the floor.There was one (1) package of opened flour tortilla's sitting on the prep table that had a use by date of 11/11/25. The FSM threw them away.There was one (1) jar of peanut butter sitting on the prep table that did not have an open or use by date. The FSM stated that it should be dated but they use it all in three (3) days normally.On 12/30/25 at 8:39 AM the can opener in the kitchen was soiled. I asked the FSM if that would be added to

the equipment cleaning schedule he is making. He said, Yes it will.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nella's at Autumn Lake Healthcare

499 Ferguson Road Elkins, WV 26241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections by not having paper towels at (2) two of the handwashing sinks in the kitchen. This failed practice had the potential to affect all residents currently living at the facility. Facility Census: 96.Findings included:a) During a walkthrough of the kitchen, on 12/29/25 at 12:50 PM, this surveyor washed his hands at the handwashing sink outside of the Food Services Manager's (FSM) office inside the kitchen and there were no paper towels to dry my hands. The FSM said, Someone must have used the last one and did not refill them. He gave me a cleaning towel to dry my hands with. During the same walkthrough, on 12/29/25 at 12:56 PM, this surveyor noticed that there were no paper towels located at the handwashing sink in the dish room. The FSM stated, There should be, but someone must have forgotten to refill them too.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet