Inspection·November 17, 2025

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 observation, record review, interview, and review of facility policy, the facility failed to ensure the resident received adequate supervision including maintaining a hazard free environment to prevent injury to Resident #30. This affected one resident (#30) out of three residents reviewed for accident hazards. The facility census was 101.Review of the medical record for Resident #30 revealed an admission date of 01/04/2010 with diagnoses including type two diabetes mellitus with hyperglycemia and diabetic neuropathy. Review of the minimum data set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #30 had intact cognition. Resident #30 required dependent assistance with showers. Review of the physician orders for September 2025 revealed an order for left foot third and fourth toe cleanse with normal saline (NS), apply mupirocin two percent (%) ointment, apply gauze, wrap with kerlix every other day (QOD), every dayshift, every other day for wound care and Doxycycline Hyclate 100 milligram (MG) give one (1) tablet by mouth (PO) two times a day (BID) for foot infection for 10 days. Review of the progress note dated 09/05/25 revealed Certified Nursing Assistant (CNA) #309 informed Licensed Practical Nurse (LPN) #300 while transporting Resident #30 out of the shower area in the shower room, Resident #30's third and fourth toe got caught on an uneven tiled area that was loose and missing tiles. CNA #309 stopped movement to get assistance while staying with the resident. Both feet were assessed by the nurse with the third and fourth digit toenails noted to be lifted, partial removal to both, and moderate amount of bloody drainage noted to areas. No visible open areas noted after cleansing with normal saline (NS) and dressing applied. Nurse Practitioner (NP) #401 updated while in the facility to evaluate with new orders to give Keflex (an antibiotic) 500 milligram (MG) three times a day (TID) for seven (7) days as prophylactic with podiatry consult and follow up. All notifications were made. An interview on 09/16/25 at 9:26 A.M. with Resident #30 confirmed she was showering on 09/05/25 and when leaving the shower her left foot toes got caught on the loose and missing tiles in the shower room on the 200 hall. Resident #30 reported she was seen by NP #401 and Podiatrist and started on an antibiotic and wound treatment. An observation on 09/16/25 at 10:31 A.M. of the shower room on the 200 hall revealed multiple areas of tile had been repaired. An interview on 09/16/25 at 10:31 A.M. with the Administrator confirmed the missing loose tile in the 200 shower room had been repaired. An interview on 09/16/25 at 10:48 A.M. with Maintenance #243 confirmed the shower room on 200 hall had loose and missing tile. Maintenance #243 reported he patched it up/repaired the missing and loose tiles in the shower room. An interview on 09/18/25 at 9:57 A.M. with Licensed Practical Nurse (LPN) #300 confirmed there was loose and missing tile in the 200 shower room and Resident #30 got her third and fourth toe on her left foot stuck on it resulting in an injury requiring treatment at the facility. An interview on 09/22/25 at 8:05 A.M. with CNA #309 confirmed Resident #30 got her third and fourth toe on her left foot caught in the loose and missing tile in the 200 shower room. Review of facility policy, Maintenance Repairs/Work Orders, dated 08/2016, (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 11/17/2025 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)