Inspection·June 14, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and policy review the facility failed to ensure a safe transfer was performed. This affected one resident (#60) of three residents reviewed for transfers. The census was 75. Findings included: Medical record review for Resident #60 revealed an admission date of 03/09/23. Diagnoses included Parkinson's disease, coronary artery disease, and cerebrovascular accident. Review of the care plan for Resident #60 dated 03/10/23 revealed Resident #60 had an activity of daily living (ADL) self-care deficit as evidenced by the inability to care for self related to physical limitations. Interventions included to transfer with two-person assistance with the use of a gait belt. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #60 required extensive assistance of two-persons for bed mobility, transfers, and toilet use. Observation of a transfer for Resident #60 on 06/13/23 at 9:40 A.M. revealed the State Tested Nursing Assistant (STNA) #140 used her hands to pull on the resident's right arm and then used her other hand underneath the left arm to pull Resident #60 up in bed to a sitting position on the side of the bed. The STNA #140 placed her right and left hands under the resident's armpits, raised the resident up and placed her in the wheelchair. No other staff members were in the room at this time. Interview on 06/13/23 at 9:45 A.M., STNA #140 verified she should have used a two-person transfer and used a gait belt when she transferred Resident #60, but she was nervous. Interview with the Director of Nursing (DON) on 06/13/23 at 10:12 A.M., revealed gait belts should be used for transfers for the resident if the care plan says so. Interview with the Unit Manager (UM) #108 on 06/13/23 at 1:20 P.M., verified Resident #60 required two-person assistance for bed mobility and transfers. Review of the policy titled Gait Belts, undated revealed gait belts will be available for use during all standing pivot transfers and when ambulating a resident who requires contact guard or physical assist. (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 3 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 06/14/2023 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)