Inspection·February 9, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #1 revealed an admission date of 06/08/22 with diagnoses including dementia, anxiety, neoplasm of the brain (cancer), and seizures. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #1 had cognitive impairment and required extensive assist for bed mobility and transfers and was totally dependent on staff for toileting. Review of the physician orders for January 2023 revealed an order for Depakote (anticonvulsant) 125 milligram (mg) used for seizures. Review of the allergy tab revealed no allergy to Depakote. Review of the pharmacy recommendation dated 11/20/23 revealed to remove allergy to Depakote if the resident can tolerate the medication. There was a written note to remove allergy with a check mark. Review of the plan of care dated 01/23/23 revealed Resident #1 was allergic to Valproic Acid a generic for Depakote. Intervention included to check all orders against the allergy list. Interview on 02/09/23 at 2:15 P.M. with the DON stated she changed the allergy tab and did not change revise the care plan. Review of the policy titled Comprehensive Care Plans, dated 08/22/22, revealed it is the policy of this facility to develop and implement a comprehensive person-center care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and metal and psychosocial needs that are identified in the resident's comprehensive assessment. Based on record review, interview, and facility policy review the facility failed to ensure the care plans for Resident #1 and Resident #9 were updated. This affected two residents (#1 and #9) of 17 resident care plans reviewed. The facility census was 56. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnosis including bipolar disorder, muscle wasting and atrophy, difficulty in walking, fracture of left femur, and personal history of traumatic brain injury. (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 02/09/2023 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)