F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and interview the facility failed to ensure Resident #46's right side non-pressure
wound was assessed and monitored and the physician was notified for wound care orders in a timely
manner. This finding affected one resident (#46) of three residents reviewed for wounds.
Residents Affected - Few
Findings include:
Review of Resident #46's medical record revealed the resident was admitted on [DATE] with diagnoses
including diabetes, heart transplant, and muscle weakness.
Review of Resident #46's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's
memory was intact.
Review of Resident #46's physician orders did not reveal an order for wound care for the open lesion on the
resident's right side.
Observation on 10/16/23 at 10:02 A.M. with Licensed Practical Nurse (LPN) Wound Nurse #808 of
Resident #46's right side revealed a foam dressing dated 10/12/23. When the dressing was removed, a 2.0
cm (centimeter) length by 3.0 cm width reddened non-pressure wound with the top layer of skin removed
was noted on the resident's right lateral side. No drainage was noted at the time of the observation.
Interview on 10/16/23 at 10:08 A.M. with Resident #46 revealed the wound on his right side just showed up
on 10/12/23, and the nursing staff put a dressing on it.
Interview on 10/16/23 at 10:08 A.M. with Licensed Practical Nurse (LPN) Wound Nurse #808 indicated she
was unaware of the open wound on Resident #46's right side as no staff had notified her.
This is an incidental finding discovered during the course of the complaint investigation.
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 2
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
10/16/2023
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, interview, and facility policy review the facility failed to ensure Resident #46's
multivitamins were stored appropriately. This finding affected one resident (#46) of three residents observed
for medication administration.
Findings include:
Review of Resident #46's medical record revealed the resident was admitted on [DATE] with diagnoses
including diabetes, heart transplant, and muscle weakness.
Review of Resident #46's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's
memory was intact.
Review of Resident #46's physician orders did not reveal a physician order for the multivitamin.
Observation on 10/16/23 at 9:45 A.M. revealed Resident #46 was in bed. On his overbed table, there was a
half-full bottle of Centrum Silver multivitamins with an underdetermined number of pills in the bottle.
Interview on 10/16/23 at 9:50 A.M. with Resident #46 revealed he self-administered the multivitamins twice
a day at lunch and dinner.
Observation on 10/16/23 at 9:55 A.M. with the Administrator of Resident #46 confirmed the resident's wife
had brought the Centrum Silver multivitamins into his room about a year ago and he self-administers the
pills at lunch and dinner. The resident stated the last time he gave the facility his multivitamins, the facility
refused to administer the medication.
Interview on 10/16/23 at 9:56 A.M. with the Administrator confirmed the Centrum Silver multivitamin
medication bottle would have to be locked up and an order obtained to administer the medications as
requested by the resident.
Review of the Medication Storage policy, effective 07/23/19, indicated medications and biological's were
stored safely, securely, and properly following manufacturer's recommendations or those of the supplier and
the medication supply was accessible only to the licensed nursing personnel, pharmacy personnel or staff
members authorized to administer medications.
This deficiency represents non-compliance investigated under Complaint Number OH00146407.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365563
If continuation sheet
Page 2 of 2
