Inspection·January 23, 2020

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete and present a discharge summary for one resident (Resident #59) out of one resident reviewed for discharge. Findings include: Record review revealed Resident #59 was admitted on [DATE] with diagnoses including type two diabetes, non-pressure chronic ulcer of the right foot, alcohol abuse, and a wedge compression fracture of the T 11 to T 12 vertebra. Review of Resident #59's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had no cognitive impairment scoring a 15 on the Brief Interview for Mental Status (BIMS). At the time of discharge, Resident #59 was independent with all transfers, ambulation, and activities of daily living. Review of Resident #59's electronic health record and paper medical record did not reveal a written discharge summary or recapitulation of his stay. Review of a progress note dated 10/22/19 at 11:07 A.M. authored by social services (SS) revealed SS reviewed Resident #49's discharge time, upcoming physician appointment, offer of home health services and subsequent decline of services, and social services fax of medication list to Veterans Administration. Review of a nurse progress note dated 10/23/19 at 6:15 P.M. revealed Resident #59's son arrived at the facility to pick up Resident #59 for discharge home. Medication packets for tonight (10/23/19) and tomorrow (10/24/19) were sent with resident. Education was provided for medications and resident appointments reviewed. Interview with Licensed Practical Nurse (LPN) #67 on 01/22/20 at 12:12 P.M. revealed when the facility became aware a discharge was upcoming for any resident, the facility obtained a discharge order from the physician. The facility then initiated an Interdisciplinary Team (IDT) discharge form to be completed by all departments. LPN #67 stated this form was completed prior to discharge and went over at the time of discharge with the resident/ responsible party, a copy was sent with the resident/ responsible party and a copy was kept in the chart. LPN #67 stated this form was for the resident to give their physicians at follow-up appointments. On 01/22/20 at 12:39 P.M., LPN #67 verified Resident #59 did not have a discharge summary present in the electronic health record or paper medical record. (continued on next page) 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 Page 1 of 3 Event ID: 365563 Printed: 05/15/2026 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 365563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumnwood Nursing & Rehab Center 275 East Sunset Drive Rittman, OH 44270 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)