Autumnwood Nursing & Rehab Center

Inspectors wroteBased on record review, observation, interview, and review of facility policy, the facility did not maintain a homelike environment. This affected six Residents (#6, #8, #25, #36, #55, and #58) out of 11 residents reviewed for environment. The facility census was 57.

Inspectors wroteBased on interviews, observations, review of the Self-Report Incident (SRI) and facility investigation, medical record review, and review of facility policy, the facility did not ensure that interventions were implemented to prevent actual elopement or the potential for elopement as required by physician orders and/or the care plan. This affected two residents (#14 and #59) out of three reviewed for elopement and had the potential to affect 11 residents (#3, #14, #15, #17, #19, #21, #28, #30, #32, #38, and #59) identified by the facility as being at risk for elopement.

Inspectors wroteBased on closed medical record review, review of a facility self-reported incident (SRI), review of facility policy, and interview the facility failed to ensure Resident #52 was free from physical restraints. Actual Harm occurred on 03/08/25 at approximately 7:00 A.M. when Resident #52 was physically restrained and tied to his wheelchair with a bed sheet by Licensed Practical Nurse (LPN) #526 in an attempt to address Resident #52's behaviors and to prevent Resident #52 from standing from the chair. Resident #52 was found by visiting Hospice LPN #603 tied to his wheelchair with a bed sheet knotted behind him. The resident was unattended, seated in his wheelchair, agitated, and reported a pain rating of a 10 on a one-to-ten scale (with ten indicating the worst possible pain). [...]

Inspectors wroteBased on observations, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure safety measures and interventions were implemented to prevent potential accidents and hazards. Actual Harm occurred to Resident #21 on 02/01/25 when the facility failed to ensure Resident #21's smoking apron was in place during smoking and Resident #21 sustained a burn from his cigarette dropping on his right thigh. The burn had full thickness tissue loss with 100 percent (%) slough (dead tissue) in the wound bed, and required debridement. This affected three residents (#21, #28 and #47) and had the potential to affect an additional five additional residents, Residents #3, #33, #40, #42, and #303 who were identified by the facility as being independently mobile, cognitively impaired and able to reach the unsecured box with cigarettes and lighters. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and the facility submitted Payroll Based Journal (PBJ) tracking information, the facility failed to ensure a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on record review, resident and staff interviews, and observation of a test tray, the facility failed to serve foods at a palatable temperature. This had the potential to affect all 54 residents residing in the facility who receive food from the kitchen.

Inspectors wroteBased on record review, interview, observations, review of chemical sanitizer directions for use, and review of dishwasher manufacturer's directions, the facility failed to properly sanitize dishware after washing, discard expired foods in a timely manner, and maintain food storage areas in a clean manner. This had the potential to affect all 54 residents residing at the facility who receive food from the kitchen.

Inspectors wrote2. Review of the medical record for Resident #2 revealed an admission date of 04/25/10 and a readmission date of 03/23/20 with diagnoses to include but not limited to heart failure, chronic obstructive pulmonary disease, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact and was independent for activities of daily living. An interview on 05/12/25 at 11:08 A.M. with Resident #2 revealed that the heater in his room did not work. Observation during a tour of the facility with the Director of Maintenance (DM) #502 on 05/12/25 at 11:19 A.M. revealed the air temperature in Resident #2's room was 69 degrees F. DM #502 verified the air temperature at the time of observation. 3. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to thoroughly assess the needs of its resident population by accurately evaluating residents with diseases, conditions, and physical and behavioral health needs to determine what resources were necessary to care for its residents competently. This had the potential to affect 37 residents (Residents #1, #3, #4, #5, #6, #8, #9, #10, #11, #14, #18, #19, #20, #21, #23, #24, #25, #26, #28, #29, #30, #32, #34, #36, #37, #38, #39, #40, #42, #44, #45, #47, #48, #152, #153, #303, and #304) who resided in the facility at time of entrance and had a psychiatric and/or mood diagnosis.

Inspectors wroteBased on review of personnel files, record review, and staff interview, the facility failed to ensure all staff received behavior health training. This had the potential to affect 37 residents (Residents #1, #3, #4, #5, #6, #8, #9, #10, #11, #14, #18, #19, #20, #21, #23, #24, #25, #26, #28, #29, #30, #32, #34, #36, #37, #38, #39, #40, #42, #44, #45, #47, #48, #152, #153, #303, and #304) who resided in the facility at time of entrance and had a psychiatric and/or mood diagnosis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment used for residents' activities of daily living (ADLs) were maintained in good working condition. This affected one resident (#26) of one resident reviewed for equipment and had the potential to affect one additional resident (#8) who utilized a shower bed for bathing. The facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had accurate advance directive orders and information in place throughout the medical record for Resident #45. This affected one resident (#45) of 34 residents reviewed for advance directives. The facility census was 54.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to report an injury of unknown origin to the Ohio Department of Health (ODH) as required. This affected one resident (#47) of two residents reviewed for reporting abuse, neglect, misappropriation or injuries of unknown origin. The facility census was 54.

Inspectors wroteBased on interview, medical record review, review of the Ohio Department of Health (ODH) Certification and Licensure System (CALS), and review of the facility policy, the facility failed to thoroughly investigate incidents of potential abuse for two residents (#47 and #52) of two residents reviewed for investigations of abuse, neglect, misappropriation, or injuries of unknown origin. The facility census was 54.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to permit Resident #302 to return to the facility after a hospitalization. This affected one (#302) of four residents reviewed for discharge. The facility census was 54.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to issue a discharge notice to Resident #302 prior to discharge. This affected one (#302) of four residents reviewed for discharge. The facility census was 54.

Inspectors wroteBased on observation, resident, family, and staff interview, record review, and review of the facility policy, the facility failed to ensure the residents received activities to meet their needs and preferences. This affected one (Resident #47) of two residents reviewed for activities. The facility census was 54.

Inspectors wroteBased on observations, interview, record review, and review of the facility policy, the facility failed to ensure a resident had physician orders for oxygen therapy and to maintain the oxygen supplies. This affected one (Resident #47) of two residents reviewed for oxygen.

Inspectors wroteBased on observations, staff interviews, record review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure residents who had indwelling medical devices and/or wounds were on enhanced barrier precautions (EBP), ensure staff wore the appropriate personal protective equipment (PPE) for residents on EBP, and ensure staff followed proper hand hygiene when providing care to the residents. This affected three residents (Resident #5, #47, and #152). The facility census was 54.

Inspectors wroteBased on residents' interview, staff interview, and review of the facility policy, the facility failed to ensure residents received mail on the weekends. This had the potential to affect residents residing in the facility. The facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to establish a grievance committee consisting of no more than one staff for every two residents or representatives. This had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on personnel record review and staff interview, the facility failed to ensure the Activities Director was qualified for the position. This had the potential to affect 54 of 54 residents. The facility census was 54.

Inspectors wroteBased on interviews, record review, and review of the facility policy, the facility failed to timely notify Resident #61's alternate Power of Attorney (POA) of a decline in health status when primary POA could not be reached. This affected one resident (Resident #61) of three residents reviewed for notification of change. The facility census was 60.

Inspectors wroteBased on observation, review of the facility menu and meal spreadsheet, review of facility policy, and interview with staff the facility failed to ensure the residents were served all the food items on the menu. This affected everyone who received their meals from the kitchen except Resident #5 who was ordered nothing by mouth. The facility census was 60.

Inspectors wroteBased on observations, review of the medical record, and interview with the staff the facility failed to ensure Resident #39 had a physician's order for a treatment to his left elbow. This affected one resident (#39) of three residents reviewed for wounds. The facility census was 60.

Inspectors wroteBased on observation, review of the medical record, review of facility policy and interviews with staff the facility failed to ensure a comprehensive skin assessment was completed after admission for Resident #1, and failed to maintain proper infection control practices and hand hygiene during wound care to promote wound healing for Resident #58. This affected two residents (Resident #1 and #58) of three residents reviewed for wounds. The facility census was 59.

Inspectors wroteBased on observations, staff interviews, policy review, and record review, the facility failed to ensure Resident #100 received timely care and services related to the resident's nasograstic tube not functioning properly. This affected one (Resident #100) of three residents reviewed to tube feeds. The facility census was 58.

Inspectors wroteBased on observations, resident and staff interviews, policy review, and record review, the facility failed to ensure intravenous dressings were changed weekly according to best nursing practice and the facility policy. This affected two (Residents #25 and #56) of three residents reviewed for intravenous dressing changes. The facility census was 58.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure Resident #46's right side non-pressure wound was assessed and monitored and the physician was notified for wound care orders in a timely manner. This finding affected one resident (#46) of three residents reviewed for wounds.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure Resident #46's multivitamins were stored appropriately. This finding affected one resident (#46) of three residents observed for medication administration.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure there was a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 56 residents currently residing in the facility.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure the care plans for Resident #1 and Resident #9 were updated. This affected two residents (#1 and #9) of 17 resident care plans reviewed. The facility census was 56.

Inspectors wroteBased on record review and interview, the facility failed to complete and present a discharge summary for one resident (Resident #59) out of one resident reviewed for discharge.

Inspectors wroteBased on medical record review, laboratory records and staff interview, the facility failed to ensure laboratory testing was completed for one of five residents (Resident #5) sampled for medication review. The facility census was 53.