Inspection·April 30, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, review of facility policy and interviews with staff the facility failed to ensure a comprehensive skin assessment was completed after admission for Resident #1, and failed to maintain proper infection control practices and hand hygiene during wound care to promote wound healing for Resident #58. This affected two residents (Resident #1 and #58) of three residents reviewed for wounds. The facility census was 59. Residents Affected - Few Findings included: 1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. He was sent out to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included diabetes, congestive heart failure, bipolar disorder, hypertension, hypothyroidism, restless leg syndrome, insomnia, depression, and Parkinson's disease. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had intact cognition and had two Stage III pressure ulcers. Review of the progress note dated 03/10/24 at 12:24 A.M. revealed Resident #1 was transported to the emergency room. Review of the progress note dated 03/14/24 at 6:30 P.M. revealed Resident #1 was readmitted to the facility. He was at the hospital for a urinary tract infection. Review of the readmission assessment dated [DATE] revealed Resident #1 had an area to his mid back and left ankle. There was no assessment or measurements completed. Review of the skin assessment dated [DATE] revealed Resident #1 had a left ankle unstageable pressure ulcer which measured 6.0 centimeters (cm) in length by 4.0 cm in width by undetermined depth. There was full thickness loss with slough noted in the wound bed. He had a mid-back wound which measured 4.5 cm in length by 2.0 cm in width by undetermined depth. There was full thickness loss with slough noted in the wound bed. On 04/30/24 at 9:24 A.M. an interview with the Director of Nursing confirmed no wound assessment or measurements were completed on Resident #1 during his readmission for five days. He stated the nurse who completed the assessment was a night shift nurse. He stated they were supposed to assess wounds on admission. 2. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. (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 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 04/30/2024 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)