Inspection·May 4, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to provide evidence of interventions included on a resident's plan of care were implemented when a resident was having self injurious behaviors. This affected one of three residents (#32) records reviewed for incidents. The facility census was 85. Findings include: Review of the medical record for Resident #32 revealed an admission date of 01/05/23. At the time of the survey, Resident #32 was at the hospital. Diagnoses included cerebral infarction, type two diabetes mellitus, schizophrenia, post traumatic stress disorder, and chronic kidney disease stage three. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/19/23, revealed Resident #32 had impaired cognition. The resident required supervision for bed mobility, one person physical assist with transfers and ambulation. Resident #32 had behavioral symptoms not directed towards others such as hitting self, pacing, disrobing in public, throwing food or bodily waste, verbal symptoms such as screaming, disrupting sounds and rejection of care. Review of the plan of care dated 07/29/22 revealed Resident #32 was at risk for behavior symptoms related to Alzheimer's disease, dementia, affects of cerebral vascular accident, alcoholism, closed head injury, mental illness, and schizophrenia with suicidal and homicidal ideation. Interventions included administer medications per physician order, attempt psychotropic drug reduction per physician orders as needed, observe for mental status/behavior changes when new medication was started or with changes in dose and provide consistent approaches when giving care. On 04/23/23 interventions added included frequent checks by staff to observe for behaviors, leave door to the room open for improved observations, and monitor for targeted behaviors such as depression, overwhelming fear, nervousness and anxiety. If the resident exhibited symptoms provide a quiet environment, monitor for thirst and hunger, provide fluids and snacks of resident's preference and redirection. Review of the plan of care dated 12/09/22 revealed Resident #32 had verbal and physical agitation and aggression, paranoia, refused medications, refused care delivery such as showers, incontinence care and meals related to cognitive impairment and mental illness. Interventions included administer medication per the physician orders, approach from slightly to the side of the resident, provide diversional activity, remove from public area when behaviors was disruptive or unacceptable, provide one on one time that was noninterrupted and non- care related, use consistent routine and caregivers for activities of daily living. (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 4 Event ID: 365576 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 05/04/2023 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)