Inspection visit
Health inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to maintain a call light and overbed
table within Resident #13's reach. This affected one resident (#13) of ten residents reviewed for
environmental/call light concerns and had the potential to affect all 106 residents residing in the facility.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #13 revealed an admission date of 03/04/25. Diagnoses included
chronic respiratory failure, congestive heart failure, chronic kidney disease, and need for assistance with
personal care.
Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/31/25, revealed Resident #13 had
moderate cognitive impairment.
Review of the care plan revised 09/29/23 revealed Resident #13 required assistance with activities of daily
living (ADL) related to decreased mobility, shortness of breath with activity, and altered cognition.
Interventions included to encourage Resident #13 to use the call light and ask for assistance when needed.
Observation and interview on 04/28/25 at 10:27 A.M. with Resident #13 revealed the resident sitting in a
wheelchair in front of a nightstand which was up against the wall left of the window with the adjacent bed
extending from the same wall toward the center of the room. Resident #13's wheelchair was alongside and
up against the left bedside, and the resident was facing the television which was against the opposite wall
of the room. The resident's overbed table which had multiple personal belongings on top including a
beverage glass and television remote control was placed on the opposite side of the room in front of the
television, out of the resident's reach. Resident #13's call light was wrapped around the left bed rail which
was located behind the resident's wheelchair and out of the resident's reach. Resident #13 complained
about being unable to reach the overbed table and not able to call the staff to help because the call light
could not be found. Both of Resident #13's feet were elevated by wheelchair footrests, and the resident was
unable to maneuver the wheelchair to locate the call light or reach the overbed table.
Interview at the time of the observation with Housekeeping Supervisor (HS) #3910 and Activity Director
(AD) #3430 who entered the room and found the call light behind Resident #13 wrapped around the
bedrail, removed it and connected to Resident #13's left side of the wheelchair within reach, then pulled the
overbed table from across the room to the resident so it was within reach. HS #3910 and AD #3430
confirmed both Resident #13's call light and overbed table were not placed within the resident's reach for
adequate use.
(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 11
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
05/05/2025
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)
F 0558
This deficiency represents non-compliance investigated under Master Complaint Number OH00164195,
Complaint Number OH00163856 and Complaint Number OH00163679.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365672
If continuation sheet
Page 2 of 11
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
05/05/2025
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observation, interview and review of facility policy, the facility failed to maintain a clean and
homelike environment. This affected four residents (#13, #35, #74 and #257) of ten residents reviewed for
environmental concerns and had the potential to affect all 106 residents residing in the facility.
Findings include:
Observation on 04/28/25 at 10:27 A.M. of Residents #13 and #35's room revealed a large amount of dirt
accumulation on the floor including underneath both beds. There were multiple pieces of paper and plastic,
pieces of used medical equipment such as what appears to be an intravenous cap and a used individual
serving coffee creamer cup. There was no trash bag in the trash can. Interview at the time of the
observation with Housekeeping Surveyor (HS) #3910 verified the findings and indicated being new to the
job and having made changes to address some of the issues. Housekeepers were not available after 5:00
P.M., so nursing assistants were supposed to assist with any visible issues until a housekeeper returned
the following day but admitted the dirt accumulation in Residents #13 and #35's room appeared to be over
more than one day.
Observation and interview on 04/28/25 at 10:56 A.M. of Residents #74 and #257's room revealed a large
amount of dirt accumulation on the floor and bathroom floor including underneath both beds. There were
multiple pieces of plastic and paper and dried spills throughout. Numerous areas of the floors and around
the bathroom toilet were darkened from dirt build-up. Resident #257 complained of the floor being overly
dirty and of housekeeping not cleaning on a routine basis. Interview at the time of the observation with
Registered Nurse (RN) #3340 verified the findings and indicated there should be a housekeeper coming
around to address it.
Observation and interview on 04/28/25 at 11:06 A.M. with HS #3910 of Residents #74 and #257's room
confirmed the dirty floors and indicated it had accumulated over more than one day. Resident #74's
overbed table had large amounts of dried spills on the tabletop and table legs. HS #3910 verified the
overbed table was not cleaned after use on a routine basis.
Review of facility policy, Housekeeping Policy/Procedure, dated 12/28/13, revealed the facility will be
maintained and cleaned to meet a home like environment for residents.
This deficiency represents non-compliance investigated under Complaint Number OH00163856 and
Complaint Number OH00163679.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365672
If continuation sheet
Page 3 of 11
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
05/05/2025
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)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Some
Based on record reviews, observations, interviews and facility policy review, the facility failed to ensure
residents received showers per resident preference and shower schedule. This affected four residents (#73,
#77, #80 and #87) of six residents reviewed for showers. The facility census was 106.
Findings include:
1. Review of the medical record for Resident #77 revealed an admission date of 4/11/25 with diagnoses
including lumbago with sciatica (low back pain radiating down the leg), difficulty in walking, atrial fibrillation
(irregular heartbeat), severe protein-calorie malnutrition, frequent falls and weakness.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 required
substantial/maximal assistance for showers and bathing. Resident #77 was also dependent on staff for all
other activities of daily living (ADL) and hygiene needs. Resident #77 was always incontinent.
Review of the facility shower schedule revealed Resident #77 was to receive showers twice weekly on
Thursday and Saturday evening. Review of shower task documentation on resident's ability to bathe self,
dated 4/12/25 and 4/18/25, revealed Resident #77 was dependent on staff to perform all bathing care and
required the assistance of two or more staff (despite the resident not receiving showers on 04/12/25 and
04/18/25). Review of 300 hallway shower sheets revealed no documented evidence of any showers
provided to Resident #77.
Observation and interview with Resident #77 on 04/28/25 at 10:18 A.M. stated she had not been receiving
showers. She complained that her hair had not been washed since she admission, and it feels very dirty.
Her hair was notably greasy and unkempt.
Observation and interview on 4/29/25 at 1:15 P.M. with Resident #77 stated again that she still had not
received a shower or had her hair washed. Her hair remained greasy and unkempt.
Observation and interview on 4/30/25 at 8:25 A.M. with Resident #77 accompanied by the Director of
Nursing (DON) revealed the resident was in the bathroom in a wheelchair with care assistance. Resident
#77 stated she was going to get her hair washed. The DON verified the resident's dirty hair and that she
had not been receiving showers as scheduled or per resident's choice. The DON also verified the absence
of shower sheets and documented complete on the shower tasks for this resident. The DON confirmed
Resident #77 did not receive showers as scheduled on 04/12/25, 04/17/25, 04/19/25, 04/24/25, or
04/26/25. The DON stated there was a recent change at the facility to no longer utilize dedicated shower
aides. All the Certified Nursing Assistants (CNAs) would assume the previous shower duties in their daily
assignments.
Review of the facility policy titled Bathing Choice Policy, dated 01/2021, revealed residents are interviewed
during the admission process regarding the frequency they want to bathe/shower. Frequency is reviewed at
least quarterly during the care planning conference, and changes are implemented if indicated by the
resident's choice.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365672
If continuation sheet
Page 4 of 11
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
05/05/2025
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)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
2. Review of the medical record for Resident #87 revealed an admission date of 01/14/25 with diagnoses of
chronic kidney disease, hemiplegia (paralysis) affecting right dominant side, muscle wasting and atrophy
(tissue shrinking), and adult failure to thrive.
Review of the MDS dated [DATE] revealed Resident #87 required moderate assistance for shower/bathing
and other hygiene needs.
Observation and interview on 04/28/25 at 2:30 P.M. revealed Resident #87 was unkept and disheveled in
appearance with noted overgrowth of facial hair. Resident #87 stated he used to receive regular showers
and assistance with the shower aides prior to facility process change, but now he does not get a shave with
his shower as requested. Resident #87 stated that now the aides just hose him down and do not clean well.
Observation of Resident #87 also revealed limited range of motion on his dominant right side.
Observation on 04/29/25 at 1:42 P.M. revealed facial hair still present. Resident #87 asked for assistance.
Concerns were forwarded and verified with the DON.
Observation and interview on 05/01/25 at 1:44 P.M. with Resident #87 in the hallway accompanied by the
DON revealed his face was clean shaven, and the resident was very happy about today's recent shower
and shave. The DON verified Resident #87 requested to have a shave with showers.
Review of Resident #87 shower sheets from March 2025 through April 2025 revealed showers were
provided on 03/12/25, 03/13/25, 03/15/25, 03/26/25, 04/02/25, 04/12/25, and 04/26/25. The facility shower
schedule revealed Resident #87 was assigned to have showers completed twice weekly every Wednesday
and Saturday during the day shift.
Review of the Treatment Record dated 04/01/25 through 04/30/25 revealed Resident #87 had a bath signed
off on 04/06/25 at 2:02 A.M. and 04/26/25 at 12:37 A.M. with rest of the dates signed off as not applicable
or left blank.
Interview with the DON on 05/01/25 at 1:30 P.M. verified the missing shower sheets, shower schedule, and
absence of regular showers and shaving for Resident #87.
Review of the facility policy titled Bathing Choice Policy, dated 01/2021, revealed residents are interviewed
during the admission process regarding the frequency they want to bathe/shower. Frequency is reviewed at
least quarterly during the care planning conference, and changes are implemented if indicated by the
resident's choice.
3. Review of the medical record for Resident #73 revealed an admission date of 03/28/25 with diagnoses
including pneumonia, chronic kidney disease stage three, wedge compression fracture with routine healing,
and cognitive communication deficit.
Review of the MDS assessment dated [DATE], revealed Resident #73 required substantial/maximal
assistance for showers and bathing. Resident #73 was also dependent on staff for all other ADL and
hygiene needs. Resident #73 was sometimes incontinent and needed substantial/ maximum assistance.
Review of the facility shower schedule revealed Resident #73 was to receive showers twice weekly on
Monday and Wednesday. Review of shower task documentation on 04/30/25 revealed Resident #73
received showers on 03/26/25, 04/07/25, 04/16/25, 04/27/25. Review of 100 hallway shower sheets
revealed no
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365672
If continuation sheet
Page 5 of 11
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
05/05/2025
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)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
documented evidence of any showers provided to Resident #73 on 03/31/25, 04/02/25, 04/09/25, 04/14/25,
04/21/25, 04/23/35, 04/28/25, and 04/30/25.
Observation and interview with Resident #73 on 04/28/25 at 10:31 A.M. revealed she had not been
receiving showers. Resident #73 complained that her hair had not been washed, and she would like her
showers. Resident #73 appeared unkempt and soiled.
Observation and interview on 04/29/25 at 10:38 A.M. with Resident #73 stated she still had not received a
shower. Resident #73 remained unkempt.
Interview on 04/28/25 at 10:37 A.M. with Resident #73 accompanied by the DON verified that she had not
received showers as scheduled or per resident's choice.
Interview on 04/30/25 at 10:43 A.M. with the Administrator confirmed Resident #73 received four showers
between 03/26/25 and 04/31/25 based on documentation provided.
Review of the facility policy titled Bathing Choice Policy, dated 01/2021, revealed residents are interviewed
during the admission process regarding the frequency they want to bathe/shower. Frequency is reviewed at
least quarterly during the care planning conference, and changes are implemented if indicated by the
resident's choice.
4. Review of the medical record for Resident #80 revealed an admission date of 01/30/25 with diagnoses
including hepatic encephalopathy, bipolar disorder, moderate protein-calorie malnutrition, pressure ulcer of
sacral region.
Review of the MDS assessment dated [DATE], revealed Resident #80 required substantial/maximal
assistance for showers and bathing.
Review of the facility shower schedule revealed Resident #80 was to receive showers twice weekly on
Sunday and Thursday. Review of shower task documentation on 04/30/25 revealed Resident #80 received
showers on 04/01/25 and 04/21/25. Review of the 100 hallway shower sheets revealed no documented
evidence of any showers provided to Resident #80 on 04/06/25, 04/10/25, 04/13/25, 04/17/25, 04/20/25,
04/24/25, and 04/27/25.
Observation and interview with Resident #80 on 04/30/25 at 9:16 A.M. stated she had not been receiving
showers. Resident #80 complained that her hair had not been washed, and she would like her showers.
Resident #80 appeared unkempt and soiled. Resident #80's hair was greasy.
Interview on 4/30/25 at 9:28 A.M. with Resident #80 accompanied by the DON verified that she had not
received showers as scheduled or per resident's choice.
Interview on 04/30/25 at 10:43 A.M. with the Administrator confirmed Resident #80 received two showers
on 04/01/25 and 04/31/25 based on documentation provided.
Review of the facility policy titled Bathing Choice Policy, dated 01/2021, revealed residents are interviewed
during the admission process regarding the frequency they want to bathe/shower. Frequency is reviewed at
least quarterly during the care planning conference, and changes are implemented if indicated by the
resident's choice.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365672
If continuation sheet
Page 6 of 11
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
05/05/2025
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)
F 0677
This deficiency represents non-compliance investigated under Master Complaint Number OH00164195,
Complaint Number OH00163856, and Complaint Number OH00163679.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365672
If continuation sheet
Page 7 of 11
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
05/05/2025
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)
F 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, staff and resident interviews, the facility failed to provide prescription
eyeglasses for Resident #2 ass ordered by the physician. This affected one resident (#2) of two residents
reviewed for vision and hearing. The facility census was 106.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses including spina
bifida, unspecified paraplegia, need for assistance with personal care, anemia, major depressive disorder,
unspecified muscle wasting and atrophy, cognitive communication disorder, and neuromuscular
dysfunction.
Review of the admission Minimum Data Set (MDS) assessment, dated 12/22/24, revealed Resident #2
required corrective lens.
Observation on 04/28/25 at 10:23 A.M. revealed Resident #2 was reading her book with a magnifying
glass. Resident #2 does not attend activities; she prefers to read in her room. Resident #2 was care
planned for in-room activities.
Record review revealed on 02/27/25 at 9:15 A.M. Resident #2 was seen by an in-house optometrist and
given an updated prescription for new vision wear. Resident #2 did not receive the new prescription
eyeglasses.
Observation and interview on 04/29/25 at 11:11 A.M. revealed Resident #2 had not received the new
prescription eyeglasses ordered by the physician on 02/27/25. Resident #2 was wearing old prescription
glasses.
Record review revealed Resident #2 was seen by a different in-house optometrist on 04/29/25 at 9:58 A.M.
for another new eyeglass prescription. Resident #2 had not received the eyeglasses at this time.
Interview on 04/29/25 at 3:04 P.M. with Social Worker #3670 verified Resident #2 never received her
prescription eyeglasses. The facility changed companies, and Resident #2 had a new eye examination, and
a new prescription was given.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365672
If continuation sheet
Page 8 of 11
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
05/05/2025
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation and interview, the facility failed to apply a palm guard as ordered for Resident
#18. This affected one resident (#18) of one resident reviewed for splints. The facility census was 106.
Findings include:
Review of the medical record revealed Resident #18 was admitted on [DATE] with a diagnosis of
hemiplegia and hemiparesis following cerebral infarction affecting the left side, muscle wasting and atrophy.
Review of the physician orders of 09/27/24 revealed Resident #18 was ordered a palm guard (a hand splint
that prevents palm injuries from severe finger flexion contracture and forms a safe barrier between
fingernails and palmar skin) to be worn daily and removed for hand hygiene and skin checks.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18
had a Brief Interview for Mental Status (BIMS) score of seven of 15, which indicated severe cognitive
impairment. Resident #18 required substantial/maximum assistance or was dependent on staff with all
activities of daily living (ADL).
Review of Resident #18's Treatment Administration Record (TAR) for the month of April 2025 revealed staff
signed off verifying Resident #18 was wearing her palm guard daily as ordered.
Observation and interview of Resident #18 on 04/29/25 at 2:17 P.M. revealed the resident was not wearing
her palm guard as ordered. The resident stated she does not often wear the palm guard, but she didn't
know why.
Observation and interview with Resident #18 and Licensed Practical Nurse (LPN) #3150 on 04/30/25 at
9:18 A.M. revealed the resident was not wearing her palm guard as ordered. LPN #3150 also confirmed
that Resident #18 was not wearing her palm guard and stated the resident often refused to wear it. LPN
#3150 then confirmed Resident #18's TAR was signed off daily during the month of April 2025 which
indicated resident was wearing her palm guard, and verified no behaviors or refusals were documented
indicating the resident's refusal to wear it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365672
If continuation sheet
Page 9 of 11
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
05/05/2025
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, resident and staff interviews, and review of the facility's smoking policy, the
facility failed to ensure Resident #3's smoking materials were secured by staff. This affected one resident
(#3) of one resident reviewed for smoking. The facility identified ten residents (#3, #23, #72, #46, #87, #90,
#83, #12, #53 and #51) as smokers. The facility census was 106.
Findings include:
Review of medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included
motor neuron disease, osteoarthritis, muscle wasting and atrophy.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/21/25, revealed Resident #3 had
impairments of both upper extremities and was dependent for most activities of daily living (ADLs), except
for eating, with which she required set-up or clean up assistance. Further review of the MDS revealed
Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively
intact.
Review of Resident #3's care plan for smoking revealed she was a supervised smoker and could not smoke
independently and needed to be supervised and assisted by staff.
Review of Resident #3's quarterly smoking assessments dated 03/19/24, 06/17/24, 10/18/24, 01/10/25 and
03/28/25 revealed resident required the facility to store her lighter and cigarettes.
Interview with and observation of Resident #3 on 04/28/25 at 5:40 P.M. revealed an empty cigarette box
and lighter in a bag attached to her wheelchair. Resident #3 stated she participated in smoke breaks daily
at 10:00 A.M., 1:00 P.M., 4:00 P.M. and 8:30 P.M. Resident #3 further stated she was unable to hold her
own cigarettes and wore a smoking apron while on supervised smoke breaks. She further stated her
cigarettes and lighter were stored in the bag on her wheelchair and staff did not store them as required.
Observation of Resident #3 on 04/29/25 at 1:55 P.M. revealed her lying in bed trying to take a nap. The
resident stated she would be up at 3:30 P.M to get ready for the 4:00 P.M. smoke break. The surveyor
observed a cigarette lighter and box of cigarettes in bag attached to Resident's wheelchair.
Observation of Resident #3 on 04/29/25 at 4:02 P.M. during her smoke break revealed Resident smoking
while wearing a smoking apron. Interview with activities staff member #3720 also on 04/29/25 at 4:02 P.M.
confirmed Resident #3's cigarettes and lighter were present in and kept in the bag attached to her
wheelchair.
Review of the facility's undated smoking policy revealed all cigarettes and lighters were to be kept in a
secured area when not in use and the smoking materials would only be disbursed by facility staff. The
smoking policy further stated the materials were to be returned to staff at the end of the smoking session.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365672
If continuation sheet
Page 10 of 11
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
05/05/2025
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, interview and facility policy review, the facility failed to ensure
appropriate infection control practices were followed in the administration of medications through Resident
#301's peripherally inserted central catheter (PICC) line. This affected one resident (#301) of one resident
observed for intravenous medication administration. The facility census was 106.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #301 revealed an admission date of 04/18/25 with diagnoses of
methicillin susceptible staphylococcus aureus infection (MSSA) (a highly resistant bacteria) to left great toe,
type two diabetes, and acute and subacute infective endocarditis. Provider orders included contact isolation
due to MSSA infection, and Cefazolin Sodium (antibiotic) two milligrams intravenously per PICC twice daily.
Observation of intravenous medication administration on 04/28/25 at 8:49 A.M. by Licensed Practice Nurse
(LPN) #4150 revealed signage on Resident #301's door identifying contact precautions (wearing gown,
gloves, and hand hygiene) to be used when entering room and providing care to the resident. LPN #4150
entered the room and donned gloves and a gown without previous hand hygiene. LPN #4150 then prepared
the antibiotic solution, primed the intravenous tubing, and placed the antibiotic medication into the
intravenous pump. LPN #4150 then went into her scrub pocket and retrieved a pen and dated/initialed the
antibiotic medication bag. LPN #4150 then scrubbed the hub of the PICC access cap with an alcohol swab
without performing hand hygiene and changing her gloves. She then flushed the PICC line with sterile
saline, connected the medication delivery tubing to the resident's PICC line and started the infusion. LPN
#4150 then removed her protective clothing, performed hand hygiene and left the room.
Interview with LPN #4150 on 04/28/25 at 9:00 A.M. confirmed she forgot to perform hand hygiene prior to
donning personal protection equipment (PPE) and prior to accessing the PICC line.
Interview with the Director of Nursing (DON) on 04/28/25 at 11:30 A.M. verified that hand hygiene should
have been performed prior to entering the room for contact isolation and prior to administering the PICC
medication after touching room equipment and clothing.
Review of the facility policy titled Medication Administration: General Guidelines dated 12/12 revealed
hands are washed with soap and water and gloves applied before administration and after contact with the
resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365672
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the May 5, 2025 survey of AUTUMN HILLS CARE CENTER?
This was a inspection survey of AUTUMN HILLS CARE CENTER on May 5, 2025. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AUTUMN HILLS CARE CENTER on May 5, 2025?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.