Inspection·August 5, 2024

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide continued mental health services and implement interventions for a resident at risk of suicide. This affected one resident (#24) of three residents reviewed for depression. The facility census was 74. Findings include: Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, bipolar disorder, major depressive disorder, contracture of muscle to right lower leg, unspecified personality disorder, and bilateral osteoarthritis of knees. Additional diagnoses of anxiety disorder and brief psychotic disorder were added on 06/19/24. Review of orders revealed Resident #24 had orders in place for Aricept tablet 10 milligrams (mg) one tablet by mouth (06/20/24); sensor bed alarm to alert staff of resident's desire to transfer and check placement every shift (06/20/24); low bed for safety (06/20/24); and lurasidone hci tablet 60 mg give one tablet by mouth once daily (08/02/24). Review of a discharge minimum data set (MDS) completed on 06/17/24 revealed Resident #24's memory was OK and her ability to make decisions required modified independence, she had an acute onset of mental status change, had delusions, refused care daily, required maximum assistance for bed mobility, and was dependent for transfers. Review of nursing note dated 06/19/24 at 9:39 P.M. revealed during an emergency telehealth visit with Psych360, Resident #24 was asked if she had suicidal thoughts and replied, yes, the voices are telling me do to it. They are saying I don't belong. When asked if she had a plan, Resident #24 stated, yes and was placed on one to one with staff at all times and charting every two hours until further orders received from physician and a Columbia Suicide Risk Assessment was completed per facility policy. Physician and Director of Nursing (DON) were made aware. Review of a Columbia Suicide Risk assessment dated [DATE] at 9:39 P.M. revealed Resident #24 had thoughts of wishing she was dead, had suicidal thoughts, suicidal intent without a specific plan, and scored a 6 indicating moderate suicide risk. Review of an additional nursing note dated 06/19/24 at 9:39 P.M. revealed Resident #24 received new orders to start Ativan 0.5 mg by mouth as needed for 14 days and risperidone 0.5 mg by mouth every 12 hours for bipolar disorder, then discontinue order once Latuda arrives from the pharmacy. Family and primary care physician (PCP) made aware. (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: 365589 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 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)