Inspection·August 25, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the code status in the hard chart/medical record matched the electronic medical record for two (Resident's #13 and #24) of 24 resident records reviewed. The facility census was 79. Finding Include: 1. Review of the medical record for Resident #13 revealed an admission date of 08/21/15. Diagnoses included disorder of circulatory system, heart failure, and chronic pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had intact cognition. Review of the physician orders for August 2022 identified orders for Do Not Resuscitate Comfort CareArrest (DNRCC-A) dated 08/07/22. Review of Resident #13's electronic chart revealed the code status matched the physician order. Review of Resident #13's hard chart on 08/23/22 at 10:14 A.M. revealed the code status form in the chart was marked Do Not Resuscitate Comfort Care (DNRCC). There was a Do Not Resuscitate (DNR) sticker on the outside of chart. Interview on 08/23/22 at 1:01 P.M. the Director of Nursing (DON) verified the hard chart code status form did not match the physician's order. 2. Review of the medical record for Resident #24 revealed an admission date of 03/23/22. Diagnoses included leukemia, dementia, cerebral infarction, and malignant carcinoid tumor of the jejunum. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #24 had severely impaired cognition. Review of the physician orders for August 2022 identified orders for Resident #24's code status to be DNRCC-A. Review of Resident #24's electronic chart revealed the code status matched the physician order. Review of Resident #24's hard chart on 08/23/22 at 10:33 A.M. revealed the code status form was (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: 365654 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 365654 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austinwoods Rehab Health Care 4780 Kirk Rd Austintown, OH 44515 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)