Health 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. Page 1 of 4 365576 365576 05/04/2023 Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nurse progress notes dated 04/23/23 at 11:26 A.M. revealed the nurse found the resident yelling out and observed him striking his face with a closed fist. Bruising was noted to bilateral brows, and eyes, sclera was red in both eyes. The nurse instructed the staff to check on the resident frequently and to leave the door of his room open. A note dated 04/24/23 at 11:45 A.M. revealed the Nurse Practitioner (NP) noted the resident was punching self in head with fists over the weekend. The resident had been noted to have contusion on his face from this behavior. The resident remained minimally communicative and refused all medications and some meals. Attempts were made to send Resident #32 to the VA for placement in an appropriate facility. The resident returned without proper placement. The resident refused to talk or interact with staff or environment. A note dated 04/25/23 at 11:10 P.M. indicated the nurse was made aware the resident was on 15 minutes checks for safety. The nurse informed staff and added to the plan of care and an in-service. Review of Resident #32's nursing progress notes were silent related to interventions provided by staff per the plan of care related to aggression, agitation and self injurious behaviors. Interviews on 05/01/23 at 2:24 P.M. and 2:29 P.M. with State Tested Nursing Assistants (STNA) #29 and #140 revealed resident behaviors were reported to the nurse. Interviews on 05/02/23 at 11:30 A.M. and 1:00 P.M. with Registered Nurse (RN) #240 and Licensed Practical Nurse (LPN) #183 revealed residents behavioral symptoms and interventions provided would be documented in the nursing progress notes. A phone interview on 05/02/23 at 2:33 P.M. with Registered Nurse (RN) #233 revealed she was familiar with Resident #32. The RN stated Resident #32 had behaviors such as refusing medications, care including showers, self injurious behaviors and would become agitated and combative with the staff. On 04/26/23 Resident #32 had been yelling and screaming out all day. Resident #32 started hitting himself, pinching himself and yelling out. RN #233 stated she tried to calm the resident down by offering fluids, foods and any diversion she could think of. The RN stated she parked her medication cart outside of Resident #32's door to keep closer eye on him. Resident #32 started hitting himself, pinching himself and yelling out. RN #233 stated she tried one to one attention which did not work. RN #32 stated nurses document behaviors and interventions in the nursing progress notes. RN #233 stated she was not sure if she documented all of the interventions she attempted on 04/26/23. The facility did not provide a policy related to resident behavioral management. This deficiency represents non-compliance investigated under Complaint Number OH00142408. 365576 Page 2 of 4 365576 05/04/2023 Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consistently assess and monitor bruising and edema of a resident's face. This affected one resident (#32) of three reviewed for incident/accidents, and change of condition. The facility census was 84. Residents Affected - Few 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 non interrupted and non care related, use consistent routine and caregivers for activities of daily living. There was not a plan of care for skin impairment related to behaviors such as bruising or edema. Review of the nurse progress notes dated 04/22/23 at 3:46 P.M. revealed Resident #32 had skin issues identified: bruising, swelling, purple bruising was noted to bilateral brows and reddened area to base of nose. The sclera to the right eye was red. The Nurse Practitioner (NP) and physician were notified of changes in condition. New orders were obtained. A note dated 04/23/23 at 11:26 A.M. revealed the nurse found the resident yelling out and observed him striking his face with a closed fist. Bruising was noted to bilateral brows, and eyes, sclera was red in both eyes. The nurse instructed the staff to check on the resident frequently and to leave 365576 Page 3 of 4 365576 05/04/2023 Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601

F 0684 the door of his room open. The physician was informed and awaiting a response. Level of Harm - Minimal harm or potential for actual harm A note dated 04/24/23 at 11:45 A.M. revealed the NP noted the resident was punching self in head with fists over the weekend. The resident had been noted to have contusion on his face from this behavior. Residents Affected - Few The nursing notes were silent on the monitoring of bruised areas or edema to Resident #32's face after initial observation on 04/22/23. Review of the Treatment Administration Record (TAR) for April 2023 revealed no monitoring of Resident #32's bruising and edema to face. Review of the paper copy of the Skin Alteration Record dated 04/23/23 provided by the Director of Nursing (DON) on 05/02/23 at 4:15 P.M. revealed Resident #32 had a purple, blue area to his left eye measuring three by five centimeters (cm), a blue/brown area to right eye measuring two cm by four cm and slight edema noted to the bridge of nose. No further documentation was provided. Interviews on 05/01/23 at 2:24 P.M. and 2:29 P.M. with State Tested Nursing Assistants (STNA) #29 and #140 revealed resident skin impairments were reported to the nurse. Interviews on 05/02/23 at 11:30 A.M. and 1:00 P.M. with Registered Nurse (RN) #240 and Licensed Practical Nurse (LPN) #183 revealed any skin impairments would be monitored and documented on the TAR and or nursing notes. A phone interview on 05/02/23 at 2:33 P.M. with Registered Nurse (RN) #233 revealed she was familiar with Resident #32. The RN stated Resident #32 had behaviors such as refusing medications, care including showers, self injurious behaviors and would become agitated and combative with the staff. On 04/26/23 Resident #32 had been yelling and screaming out all day. The RN stated she tried to calm him down by offering fluids, foods, and any diversion she could think of. The RN parked her medication cart outside of the residents room [NAME] keep close eye on him. RN #233 stated skin impairments would be documented in nursing progress notes and on the TAR. The facility did not provide a policy on non- pressure skin impairment. This deficiency represents non-compliance investigated under Complaint Number OH00142408. 365576 Page 4 of 4