Inspection·July 8, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure pain medication was ordered and was timely available for administration for Resident #26. This affected one resident (#26) of three residents reviewed for medication administration. The facility census was 105. Findings include: Review of the medical record for Resident # 26 revealed an admission date of 06/13/24 with diagnoses including malignant neoplasm of the pelvic bones, sacrum, coccyx, scapula, skull, and face (bone cancer), chronic obstructive pulmonary disease, prediabetes, hypertension, and the presence of atherosclerotic heart disease of the coronary artery with the presence of aortocoronary bypass graft (bypass due to the narrowing of arteries that supply blood to the heart muscle). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of the physician order dated 06/13/24 revealed an order for the administration of Morphine 30 milligrams (mg) (opioid pain medication) twice a day. Review of the care plan dated 06/13/24 revealed Resident #26 was at risk for pain related to cancer. An intervention was to administer pain medication as ordered and monitor for effectiveness. Review of the nursing progress notes dated 06/13/24 revealed a family member of Resident #26 was upset that medications were not available for administration. The family member was educated that medications must be verified and signed by the prescriber. The family member offered to provide Resident #26's pain medication that was available at home. Review of Nurse Practitioner notes from 06/13/24 and 06/14/24 revealed no documented evidence Resident #26's pain medication was ordered. An interview with Licensed Practical Nurse (LPN) #515 on 07/02/25 at 9:00 A.M. revealed an attempt was made to obtain a pull code (a code to enter to unlock a medication storage box that contains controlled substance medications for immediate use when the facility has not yet received the pharmacy shipment) on 06/13/24. The provision of the code was denied by the pharmacy because the pharmacy had not yet received the signed order for the pain medication from the prescriber. An interview with the Director of Nursing (DON) on 07/02/24 at 1:42 P.M. verified the signed order (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 07/08/2024 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)