Inspection·May 5, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a complete discharge for Resident #103. This affected one resident (#103) of three reviewed for discharge. The facility census was 101. Findings include: Review of the medical record for Resident #103 revealed an admission date of 02/21/23 and a discharge date of 04/09/23. Diagnoses included encephalitis (inflammation of the brain tissue), pneumonia, diabetes, and chronic obstructive pulmonary disease (COPD). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 had intact cognition. He required extensive assistance of two people for bed mobility, transfers, dressing, toilet use, extensive assistance of one person for hygiene. Review of the care plan dated 02/27/23 revealed Resident #103's plan was to discharge to his mother's home. Review of a nursing progress note dated 04/09/23 revealed Resident #103 was discharged to his niece and mother by private car. He had all belongings and medications on discharge. Review of the physician order dated 04/09/23 revealed an order to discharge to home with physical therapy. Review of the Discharge summary dated [DATE] revealed an order was obtained from the physician, and Resident #103 was sent home with medicine. There was no evidence home health care (HHC) or therapy arrangements were made, necessary medical equipment arrangements were made, or follow up appointments were scheduled. The discharge summary was signed by Resident #103 on 04/09/23. Review of the physical therapy (PT) Discharge summary dated [DATE] revealed Resident #103 continued to require assistance with activities of daily living (ADL). He had all necessary medical equipment. Review of the occupational therapy (OT) Discharge summary dated [DATE] revealed a recommendation to discharge with HHC for OT services. Interview on 04/25/23 at 6:54 A.M. with Social Worker #208 revealed she did not complete the discharge summary for Resident #103. She did make a referral for HHC, but did not have documented evidence (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: 365672 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 365672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Hills Care Center 2565 Niles Vienna Rd Niles, OH 44446 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)