Autumn Hills Healthcare Community

In the surveyor’s words

From the most serious findings on record at Autumn Hills Healthcare Community, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 19, 2022

  Based on observation, interview, and review of the Ohio Department of Health, Department of Agriculture 2019 food code revealed the facility failed to serve food to residents in a sanitary manner to prevent infection. This had the potential to affect 52 residents who receive food from the kitchen. The facility identified two (Resident's #9 and #159) who did not receive food by mouth. The facility census was 54. Findings include: Observation on 05/16/22 at 12:08 P.M. revealed Dietary #325 plating food with no gloves on. Her nails appeared painted. She then stopped serving food and reached on top of her head grabbed her safety goggles and placed them back on her face. No hand hygiene was performed. Dietary #325 then began immediately began plating food again. […]

• No harm, potential for more than minimal, isolatedF578Apr 14, 2026

  Based on record review, interview and review of the facility policy, the facility failed to ensure advance directives were consistent across the medical record. This affected one resident (#7) of five residents reviewed for advance directives. The facility census was 57.Findings include:Review of Resident #7's medical record revealed an admission date of 02/04/26 and diagnoses including syncope and collapse, altered mental status, hypertension, atrial fibrillation, generalized anxiety disorder and vascular dementia with agitation.Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment.Review of Resident #7's physician's orders revealed an order dated 03/09/26 for an advance directive of Do Not Resuscitate Comfort Care… […]

• No harm, potential for more than minimal, isolatedF550May 19, 2022

  Based on observation, interview, and record review the facility failed to ensure Resident #36 received his meal at the same time as the other residents. This affected one of three residents (Resident's #28, #36 and #49) reviewed for dining. The facility census was 54. Finding include: Review of the medical record revealed Resident #36 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Summary (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was moderately cognitively impaired with fluctuating periods of inattention, required supervision and set-up only for eating, had a significant weight loss and an infection to his foot. […]

• No harm, potential for more than minimal, isolatedF689May 19, 2022

  Based on interview, observation, record review, and policy review the facility failed to ensure Resident #26 had fall interventions implemented according to physician orders and/ or care plan. This affected one resident (Resident #26) of four residents (Resident's #26, #36, #37 and #45) reviewed for falls. This had the potential to affect 23 residents (Resident's #4, #12, #16, #18, #19, #24, #26, #27 #29, #31, #33, #35, #36, #37, #38, #45, #47, #49, #52, #53, #55, #158 and #159) at high risk for falls. The facility census was 54. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)], acute respiratory failure with [CONDITION(S)], diabetes, and muscle weakness. […]

• No harm, potential for more than minimal, isolatedF690May 19, 2022

  Based on observation, interview, record review, and policy review the facility failed to maintain the indwelling urinary catheter bag in a manner to prevent urinary tract infection. This affected one (Resident #37) of one resident reviewed for an indwelling urinary catheter. The facility census was 54. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders for Resident #37 dated 12/16/21 revealed to change the catheter and drainage bags based on clinical indications such as infection, obstruction, or when the closed system was compromised. […]