Inspection·August 8, 2019

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #11 revealed an admission date of 01/04/14. Diagnoses included chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease stage three and adult failure to thrive. Residents Affected - Some Observation on 08/07/19 at 8:33 A.M. revealed Resident #11's oxygen tubing was dated 07/26/19. Interview with the Director of Nursing (DON) on 08/07/19 at 8:33 A.M. verified Resident #11's oxygen tubing was dated 07/26/19 and that it should be changed weekly. 5. Record review of Resident #61 revealed an admission date of 09/18/17. Diagnoses included cirrhosis of liver, tobacco use and diabetes mellitus. Observation on 08/07/19 at 8:35 A.M. revealed Resident #61's oxygen tubing was dated 07/26/19. Interview with the Director of Nursing (DON) on 08/07/19 at 8:35 A.M. verified Resident #61's oxygen tubing was dated 07/26/19 and that it should be changed weekly. Review of the facility Oxygen Administration policy, dated 07/2017, revealed to change all tubing and masks as per state protocol and label with date and initials. 3. Review of Resident #24's medical record revealed an admission date of 01/12/18 with the admitting diagnoses of congestive heart failure (CHF), obesity, cardiomyopathy and atrial fibrillation. Review of the resident's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a BIMS score of 15. The MDS indicated the resident received oxygen therapy. Review of the plan of care dated 12/21/17 revealed the resident has altered respiratory status/difficulty breathing related to chronic obstructive pulmonary disease. Interventions included to assist resident/family/caregiver in learning signs of respiratory compromise, monitor for signs/symptoms of respiratory distress and report to physician as needed and provide oxygen as ordered at four liters per minute via nasal cannula. Review of the resident's monthly physician's orders for August 2019 revealed orders dated 06/19/19 for oxygen at four liters via nasal cannula as needed and check oxygen saturation rates every shift. On 08/05/19 at 10:32 A.M., an observation of the resident's oxygen concentrator revealed the oxygen cannula tubing and humidifier bottle were not dated. On 08/07/19 at 9:50 A.M., an interview with Registered Nurse (RN) #138 verified the resident's oxygen cannula tubing and humidifier bottle were not dated. Based on record review, observations, staff interview and facility policy review, the facility failed to ensure oxygen tubing was dated for Resident #11, #24, #61, #277 and #280. Additionally two resident's oxygen tubing (#11 and #61) were not changed on a weekly basis. This affected five residents (Resident #11, #24, #61, #277 and #280) reviewed for oxygen. The facility identified 28 residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 2 of 5 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 0695 who used oxygen in the facility. The facility census was 79. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Some 1. Record review for Resident #277 revealed an admission date of 07/31/19 with medical diagnoses including cardiomegaly, pleural effusion, acute respiratory failure with hypoxia, persistent atrial fibrillation, cardiomyopathy, hemothorax and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 08/07/19, revealed Resident #277's cognition was intact. Review of Resident #277's admitting physician orders revealed an order for oxygen four liters per minute (lpm) as needed (prn). Observation on 08/05/19 at 9:47 A.M. revealed the resident in her room wearing oxygen via nasal cannula. The resident's oxygen tubing was not dated. Interview on 08/05/19 at 9:57 A.M. with Licensed Practical Nurse (LPN) #93 who stated the nurses didn't date the oxygen tubing. LPN #93 stated a respiratory company did it weekly when they came to the facility. LPN #93 verified Resident #277's tubing was not dated. 2. Medical record review for Resident #280 revealed an admission date of 08/02/19. Medical diagnoses included hypertension, chronic obstructive pulmonary disorder, shortness of breath, atrial fibrillation with rapid ventricular rate, and congestive heart failure. Observation on 08/05/19 at 2:40 P.M. revealed Resident #280 in his bed with oxygen via nasal cannula and the oxygen tubing was not dated. Interview on 08/05/19 at 2:41 P.M. with LPN #93 who verified Resident #280's oxygen tubing was not dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 3 of 5 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on medical record review and staff interview, the facility failed to identify and monitor target behaviors for a resident receiving psychotropic medications. This affected one (Resident #45) of five residents for unnecessary medications. Findings include: Review of Resident #45's medical record revealed an admission date of 11/20/17 with the admitting diagnoses of Parkinson's disease, obesity, tremors and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/19, revealed the resident had clear speech, usually understood others, made himself understood and had no cognitive deficit as indicated by a Brief Interview for mental Status (BIMS) score of 15. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors. The MDS indicated the resident received antipsychotic and antidepressant medications. Review of the resident's plan of care, dated 04/28/18, revealed the resident was at risk for a change in mood related to history anxiety/panic disorder and major depressive disorder. Interventions included to administer medications per physicians orders, assess for physical/environmental changes that may precipitate change in medications, attempt gradual dose reductions per physician's orders, evaluate effectiveness and side effects of medications, implement non-pharmacological interventions, therapies, observe for mental status/mood state changes when new medication was started or with dose changes and validate feelings or loss. Review of the resident's monthly physician's orders for August 2019 revealed orders, dated 11/20/17, for Depakote (anticonvulsant) ER 250 milligrams (mg.) by mouth twice a day, on 04/30/18 Abilify five mg. by mouth daily for major depression and on 10/15/18, Zoloft (antidepressant) 150 mg, by mouth daily. Review of the resident's medical record failed to provide target behaviors and monitoring of the target behaviors for the use of the psychotropic medications. On 08/06/19 at 4:06 P.M., an interview with the Director of Nursing (DON) verified the lack of identifying target behaviors and the monitoring of behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 4 of 5 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on staff interviews and observation, the facility failed to have a properly working call light system. This affected all 79 residents in the facility. The facility census was 79. Residents Affected - Many Findings include: During tour of the facility on 08/05/19 at 8:00 A.M., it was noted the call light system was not properly working. The individual room lights would light up when a resident pushed the call light button, but the alarm system placed in the halls would not ring out. It was also observed that the state tested nurse aides (STNAs) were not aware when a call light came on except when looking down the direction of the light. Interview with the Administrator on 08/05/19 at 9:00 A.M. revealed when a resident puts on their call light, the light would light up outside of the room and a signal would cause a buzzing sound to alarm the STNAs. The Administrator confirmed the call light system was not working properly. Interview with Maintenance #58 on 08/06/19 at 2:47 P.M. revealed the system has been intermitted for approximately three weeks. He revealed a plan to totally replace the system was in place. He stated on 08/07/19 at 8:35 A.M. the new system would start being installed on 09/02/19. Until then, the residents would keep their bells and use the call lights as well. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 5 of 5