Inspection·July 31, 2024

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 observations, review of the medical record, and interview with the staff the facility failed to ensure Resident #39 had a physician's order for a treatment to his left elbow. This affected one resident (#39) of three residents reviewed for wounds. The facility census was 60. Residents Affected - Few Findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, kidney disease, obstructive sleep apnea, spinal stenosis, pressure ulcer to the left heel, Alzheimer's disease, dementia, glaucoma, obstructive and reflux uropathy, and benign prostatic hyperplasia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severely impaired cognition. Review of the July 2024 physician's orders revealed Resident #39 did not have an order for a treatment to his left elbow. Review of the progress notes from 07/15/24 to 07/29/24 revealed no documentation Resident #39 received a skin tear or an order for a skin tear to the left elbow. Observation of wound care on 07/31/24 at 9:30 A.M. revealed the Assistant Director of Nursing (ADON) provided wound care to Resident #39 with no concerns. The dressing was dated 07/31/24. His wound was approximately the size of a quarter, about 0.1 centimeters deep. The wound bed was red. During this wound observation, it was noted that Resident #39 had a border foam dressing to his left elbow with no date. On 07/31/24 at 9:45 A.M. an interview with the ADON confirmed Resident #39 had a dressing on his left elbow with no date as to when it was placed, and she had no order for a dressing to the left elbow. Observation of the wound at this time revealed the dressing had a moderate amount of brown drainage on the old dressing. He had a small skin tear on his left elbow. She stated she would get it cleaned up and get an order for a treatment. On 07/31/24 at 1:25 P.M. an interview with the ADON revealed Resident #39 had a shower on 07/30/24 and there was no documentation of a skin tear to his left elbow, and the hospice nurse was at the facility on 07/30/24 also and had not mentioned he had a skin issues so she was not sure where the skin tear had come from or who had placed the dressing on his left elbow, but she did have a call out to the agency nurse who had worked the night before and ask her about it. (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 07/31/2024 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)