Health inspection·June 13, 2019

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of the resident council minutes, resident interview, staff interview and review of the facility policy, the facility failed to follow through on resident requests voiced during the resident council meetings. This had the potential to affect one (#39) of three residents who regularly attend resident council. The facility census was 45. Residents Affected - Few Findings include: Review of the resident council minutes dated 08/28/18, under the old business section, revealed a request for a bench for outside had not been completed or approved. The residents would like a different view to give an opportunity to view wildlife. New business indicated Resident #39 would like to see a bench with higher seats out on the patio. Review of the resident council minutes dated 09/27/18 revealed no response from maintenance yet regarding the bench. Review of the resident council minutes dated 10/29/18 revealed, under the old business section, Maintenance Director (MM) #121 stated he had asked about building benches with higher seats. Review of the Resident/Family Council Response Form dated 11/07/18 revealed one bench had to be removed as it had been unsafe. Working on getting a new one. signed by MM #121. Review of the minutes dated 11/26/18 revealed, old business, MM #121 had removed an old bench and was working on getting a new one. Review of the minutes dated 12/21/19 minutes revealed the old business reflected the benches were discussed again. review of the minutes dated 03/08/19 revealed the old business reflected the benches. Review of the minutes dated 02/28/19 revealed the issue regarding the bench remains unresolved. A Resident/Family Council Response Form signed on 03/01/19 by MM #121 revealed a bench :will be purchased soon or built. Review of the minutes dated 05/07/19 revealed residents requested a light switch guard be placed in the day room, to deter a fellow resident from turning the lights off frequently. The Resident/Family Council Response Form, signed on 05/10/19, by the Administrator revealed activity to make a sign for the light. Random observations on 06/10/19, 06/11/19 and on 06/12/19 up to 1:45 P.M. revealed no signage or cover near the light switch in the day room. There was no bench located outside. Interview on 06/12/19 at 2:00 P.M. with Resident #39 revealed the facility had been asked numerous times, unable to recall when the first time was, for a new bench for outside. The old one was extremely hard for her, in particular, to rise from. Interview on 06/12/19 at 2:13 P.M. with the Administrator verified the bench has not been built yet. The administrator stated the bench must be built outside as there was no workshop on the grounds. Interview on 06/12/19 at 4:13 P.M. with the Activity Director #133 revealed the requests should (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 6 Event ID: 366217 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 366217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Court 1925 E Fourth St Ottawa, OH 45875 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)