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Inspection visit

Inspection

WESTMORELAND PLACECMS #36559722 citations on this visit
22 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 22 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on record review and staff interview the facility failed to notify the physician of changes in a resident's condition. This affected one Resident (#87) of one reviewed for behavior and mood. The facility census was 120. Findings include: Review of Resident #87's electronic medical chart revealed a admission date of 01/08/19 with the following diagnoses: personal history of traumatic brain injury, moderate protein-calorie malnutrition, anxiety disorder, opioid dependence-in remission, unspecified convulsions, hydrocephalus, and bipolar disorder. Review of Resident #87's care plan dated 09/11/18 revealed the resident was at risk for adverse reactions and side effects due to receiving psychotropic medication related to bipolar disorder. The interventions included document mood and behavior changes when they occur, monitor and record the occurrence of targeted behaviors including violence or aggression towards staff or others and document per facility protocol. Review of Nurse's progress notes revealed on 07/03/19 a family member was visiting a loved one last night on this unit and reported this resident followed her and her granddaughter to the double doors where she was trying to exit. They turned and went back to the elevator to try to get on it, without this resident, but he followed her there also. The elevator doors opened and the visitor stepped on the elevator while a nursing aide called to the resident to come back but he would not. He reached out and grabbed the visitor by her hair and yanked her backward then put his hand around her throat and held her against the door refusing to let go. The granddaughter was screaming. The nurse aide called out to the nurse, who was in the medication room, and the nurse intervened. The resident let go of the visitor and the visitors were able to exit the building. The incident was reported by the nurse and the aide on duty to the nurse who wrote the progress note. Review of physician's orders dated 07/22/19 revealed an order for Seroquel Tablet 50 milligram (mg) with instructions to give one tablet via peg tube at bedtime for bipolar disorder. Interview with Licensed Practical Nurse (LPN) #155 on 08/21/19 at 2:25 P.M. revealed the nurse worked regularly on the locked unit and with the resident. The LPN indicated she was not aware of any aggressive or violent incidents involving the resident. The LPN stated the resident had never acted aggressively toward the staff or other residents to her knowledge. Interview with the resident's physician on 08/21/19 at 2:30 P.M. revealed the physician was not (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 20 Event ID: 365597 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0580 Level of Harm - Minimal harm or potential for actual harm aware of any aggressive or violent incidents involving the resident. The physician indicated he was on vacation for a week in the month of July. The physician stated due to the resident's brain injury, behaviors could be unpredictable and he could change without warning. The physician stated the behavior he witnessed was mostly inappropriate language used by the resident. The physician denied the resident had ever acted aggressively toward staff or other residents to his knowledge. Residents Affected - Few Interview with the unit manager, LPN #59 on 08/21/19 at 4:02 P.M. revealed the LPN was the unit manager at the time of the incident. LPN #59 denied being notified of the incident by any staff. LPN #59 indicated the resident had never acted aggressively toward the staff or other residents to her knowledge. Interview with the Director of Nursing (DON) on 08/21/19 at 4:03 P.M. revealed the DON was able to confirm the incident had occurred as reported in the nurse's note by the nurse on duty, LPN #52. LPN #52 confirmed to the DON she did not report the incident to any administration. The DON indicated she was unaware of the incident. The DON stated had LPN #52 reported the incident, the resident would have been placed on one to one supervision until the resident's agitation and aggression was resolved. The physician would have been notified and the resident's behaviors would have been closely monitored following the incident. The DON confirmed no interventions were put in place following the incident due to not being aware it had occurred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 2 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the closed medical record for Resident #114 revealed an admission date of [DATE] and a discharge date [DATE] when the resident expired in the facility. Diagnoses included malignant neoplasm of lung, secondary malignant neoplasm of brain and bone, liver cell carcinoma, and chronic atrial fibrillation. Review of care conference note dated [DATE] revealed Resident #114's and her families goal was for her to return home on [DATE] and to receive more therapy. Review of social service note dated [DATE] revealed Resident #114 had no cognition deficits and was at facility for short term rehab stay with plans to return home after discharge. She was doing very well in therapy and walking one hundred feet. Review of nurses notes dated [DATE] at 2:00 A.M. revealed Resident #114's family stated she was restless and trying to get out of bed. Review of nurses notes dated [DATE] at 9:00 A.M. revealed Resident #114 was weaker and had complaints of dizziness. She was assisted to bed and waiting transport to doctors appointment. Review of nurses notes dated [DATE] at 9:36 A.M. revealed Resident #114 was found on the floor when she stated she was sitting on side of bed lost her balance and fell. Review of nurses notes dated [DATE] at 11:00 A.M. revealed Resident #114's family decided to keep her in facility for a while longer due to weaker and lethargic. Review of nurses notes [DATE] at 3:30 P.M. revealed Resident #114 had expired. Review of the medical record revealed her full care plan had not yet been developed and there was no baseline care plan in place to address any fall risk and interventions until the comprehensive care plan was developed. Interview was conducted on [DATE] at 1:54 P.M. with the DON and she verified there was no baseline care plan done for Resident #114. Based on medical record review and resident and staff interview the facility failed to complete baseline care plans. This affected two Residents (#77 and #114) of 24 residents reviewed for baseline care plans. The facility census was 120. Findings include: 1. Review of the electronic medical record for Resident #77 revealed an admission date of [DATE] with the following diagnoses: acute kidney failure, other fatigue, chronic obstructive pulmonary disease (COPD), essential hypertension (high blood pressure), other sequelae of other cerebrovascular disease, and hyperlipidemia. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #77 had moderate cognitive impairment. No behaviors were exhibited by the resident. Resident #77 required total dependence with the assistance of two persons for bed mobility, transfers, dressing, and toileting. The resident required total dependence with assistance from one person for personal hygiene and bathing. The resident was non-ambulatory and used a geriatric wheelchair (geri chair) for mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 3 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident #77's electronic and hard medical records PM revealed there was no baseline care plan in either chart. An interview with Resident #77 on [DATE] at 2:45 PM revealed the resident's daughter was named as the resident's Power of Attorney (POA). The resident stated she had not been included in any discussion of her plan of care or involved in any discharge planning. An interview with the Director of Nursing (DON) on [DATE] at 3:03 P.M. confirmed a baseline care plan was not completed for Resident #77. The DON stated the facility identified that baseline care plans were not being completed on [DATE], but still had not done one for Resident #77. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 4 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interview, the facility failed to develop a comprehensive care plan for residents. This affected one (#58) of 24 residents reviewed for care plans. The facility census was 120. Findings include: Review of Resident #58's electronic medical record revealed an admission date of 07/02/18 with the following diagnoses: Parkinson's Disease, primary generalized osteoarthritis, dementia in other diseases classified elsewhere without behavioral disturbance, polyneuropathy, other chronic pain, major depressive disorder, and insomnia. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 had moderate cognitive impairment. The resident required limited assistance with one person assistance for activities of daily living. Review of the progress notes dated 07/30/19 revealed the nurse spoke with Resident #58's physician about restarting Glycopyrrolate medication. The medication was only written for a 30 day order and it had helped with excess saliva. The physician gave the order to restart and continue the medication. Review of physician's orders dated 07/30/19 revealed Glycopyrrolate tablet one milligram (mg) give 1/2 tablet twice daily for increased secretions. Observation and interview of Resident #58 on 08/20/19 at 2:23 P.M. revealed the resident in his room, sitting in a recliner chair. The resident had a towel laid across his chest. The resident's red shirt was observed to be wet below the towel. The resident indicated he used the towel to cover his shirt due to excessive drooling from his bottom lip. The resident reported the saliva was an effect from his Parkinson's Disease diagnosis. The resident stated he didn't want people guessing what was wrong with him. Observation of Resident #58 on 08/21/19 at 2:25 P.M. revealed the resident in his room, sitting in his recliner chair. The resident had visible drool coming from his bottom lip, dripping on to the front of his shirt. The resident was not wearing anything to protect his clothing from becoming wet. Interview with Licensed Practical Nurse (LPN) #155 on 08/21/19 at 2:32 P.M. confirmed the LPN was aware of Resident #58's excessive drooling. LPN #155 indicated the resident had been on a couple of different medications to try to control the secretions. LPN #155 confirmed the resident often had a wet shirt from the drooling. LPN #155 stated the resident's wife had provided a clothing protector for the resident to wear during meal times. The clothing protector had not been offered to the resident to wear at all times to protect his clothing. LPN #155 stated the resident had not complained that the wet shirt bothered him. LPN #155 stated the resident's shirt could be changed anytime the resident requested but the staff did not offer to change the resident's shirt. Interview with Resident #58's physician on 08/21/19 at 2:45 P.M. revealed the resident's excessive secretions was difficult to treat because many of the medications that could help to control it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 5 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0656 Level of Harm - Minimal harm or potential for actual harm would not be good for the resident's cognition and were not recommended for elderly patients. The physician indicated the resident's condition had improved since the current medication had been started. Interview with the Director of Nursing on 08/22/19 at 10:55 A.M. confirmed Resident #58's care plan did not address the resident's excessive drooling because she was not aware it bothered the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 6 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, review of facility Self-Reported Incident (SRI) and facilities policy review the facility failed to update and revise residents care plans. The facility also failed to involve and invite residents to their care conference meetings and to involve the residents in their care plan. This affected six Residents (#23, #59, #60, #68, #77, and #87) out of 27 residents reviewed for accuracy of care plans and care planning participation. The facility census was 120. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 05/21/18 with diagnoses including intracranial injury with loss of consciousness, dysphagia, bipolar, depression, acute respiratory failure, pneumonitis due to inhalation of food, and secondary malignant neoplasm of lung. Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed he had no cognitive deficits and received a mechanically altered diet. Review of nurses notes dated 06/19/19 revealed Resident #23 was found at pop machines drinking pop and stated he will drink what he wants and how he wants. Education was given on risks and he stated he did not care. Review of physician progress note dated 07/10/19 revealed Resident #23 drinks four plus sodas a day and refused to follow dietary restrictions and consistency modified drinks. Review of physician progress note dated 07/24/19 revealed Resident #23 was sent to the hospital and treated for aspiration pneumonia. He was noncompliant with dietary restrictions and drinks fluids that are not thickened and eats what he wants despite concerns for aspiration. He refused peg tube. Review of physician order dated August 2019 revealed Resident #23 was on nectar thickened consistency fluids related to oropharyngeal dysphagia. Review of Resident #23's care plan revealed no mention of him being non complaint with thickened liquids in his nutritional, activities of daily living, or behavioral care plan. There was no care conference documentation in the medical record. Interview was conducted on 08/20/19 at 10:26 A.M. with Resident #23 and he stated he was not told of any orders, was not part of his care plan development, and had never attended a care conference meeting. Follow up interview was conducted on 08/20/19 at 10:54 A.M. with Resident #23 and he stated he did not like his liquids thickened. Observation was conducted on 08/20/19 at 2:06 P.M. with Resident #23 and he was drinking pop out of a can and it was not thickened. Interview was conducted on 08/21/19 at 8:57 A.M. with Social Service Staff #143 and she stated they did not have any in house care conference with Resident #23. She stated he did have a guardian and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 7 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0657 Level of Harm - Minimal harm or potential for actual harm he would call with any questions. She verified there was no scheduled care conference being done and that Resident #23 was not invited to attend a care conference. Interview was conducted on 08/22/19 at 12:37 P.M. with Registered Nurse (RN) #40 and she verified Resident #23's care plan did not include noncompliance with thickened liquids. Residents Affected - Some 2. Review of the medical record for Resident #59 revealed an admission date of 02/26/16 with diagnoses including cerbrovascular disease and depression. Review of annual MDS dated [DATE] revealed Resident #59 had no cognitive deficits and no dental concerns. Review of dental note dated 02/25/19 revealed Resident #59 had lost his lower dentures and wanted them replaced. Impressions would be done on the next visit and recommended full lower denture. Review of dietary note dated 07/19/19 revealed Resident #59 received a regular diet with no chewing or swallowing difficulties noted. If approved, he will get impressions on next dental visit. Review of Resident #59's care plan did not indicate anywhere that his lower dentures was missing. Interview was conducted on 08/19/19 at 11:23 A.M. with Resident #59 and he stated he had lost his bottom dentures and was waiting on social security to get new ones. He stated some difficulty with eating but stated he gets by. Interview was conducted on 08/22/19 at 9:51 A.M. with Social Service Staff #87 and she stated the dentist indicated they were waiting on medicaid approval for Resident #59's dentures. Interview was conducted on 08/22/19 at 12:34 P.M. with RN #40 and she verified Resident #59's care plan was silent for any missing dentures. 3. Review of the medical record for Resident #68 revealed an admission date of 07/01/19 with diagnoses including depression, obesity, hypertension, Parkinson's, and obstructive sleep apnea. Review of admission MDS dated [DATE] revealed the resident had some moderate cognitive deficits and displayed no behaviors. Review of hospice note dated 07/19/19 revealed family spoke to hospice in regards to Resident #68'2 sex drive and pornographic pictures found on his I-pad. Review of hospice note dated 07/29/19 revealed nurse spoke with Resident #68 about concerns with sex drive and he declined wanting any medication to decrease sex drive. Review of social service note dated 07/30/19 revealed Resident #68 was having sexual behaviors while staff was providing care and hospice was notified. Review of hospice note dated 08/01/19 revealed nurse spoke with Resident #68 regarding his actions and behaviors towards staff and educated him on inappropriate behavior. Review of facilities SRI dated 08/19/19 revealed that on 08/16/19 an aide went into Resident #68's room to answer call light and he stated he needed help cleaning himself up from an incontinent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 8 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0657 Level of Harm - Minimal harm or potential for actual harm episode. Resident #68 had been watching porn to become aroused in hopes that aide would touch him. After resident's condition subsided, the aide and nurse did help with incontinent episode. Resident #68 claims aides said they would return and never did. The facility educated staff to always answer Resident #68's call light, always enter with two staff and return quickly several times if necessary to help Resident #68 once it was appropriate. Residents Affected - Some Review of Resident #68's care plan revealed he had no behavioral care plan and no mention of sexual inappropriateness in care plan. Interview was conducted on 08/19/19 at 3:22 P.M. with Resident #68 and he stated the aides would not change him and he felt it was intentional. Interview was conducted on 08/19/19 at 4:02 P.M. with the Administrator and he stated Resident #68 watches porn and gets himself aroused and aides tell him they will be back. He stated he would report the allegation and investigate it. Interview was conducted on 08/20/19 at 2:18 P.M. with State Tested Nursing Assistant (STNA) #130 and she stated Resident #68 had sexual behaviors such as will watch porn and sometimes it was so loud it could be heard in the hallways. She stated Resident #68 would ask the aides to touch him inappropriately and he has made sexual advances. She stated they would go back at a later time to assist him and have also told him to turn down the porn so others could not hear it. Interview was conducted on 08/21/19 at 1:47 P.M. with Licensed Practical Nurse (LPN) #89 who revealed not being aware of his sexual behaviors until a couple days ago and verified there was no care plan in place to address behaviors. Interview was conducted on 08/21/19 at 2:02 P.M. with Social Service Staff #143 and she stated she was just made aware of Resident #68's sexual behaviors when the facility filed a SRI. She stated she would talk to staff and put a behavioral plan of care in place. Review of facilities Care Conferences, Resident and Family Participation Policy dated 08/07/09 revealed each resident and his/her family or legal representative are encouraged to participate in the development of the resident's comprehensive assessment and care plan and are invited to attend and participate in the resident's assessments and care planning conferences. 4. Review of the electronic medical record for Resident #60 revealed an admission on [DATE] with the following diagnoses: spinal stenosis, difficulty walking, unspecified osteoarthritis, weakness, foot drop of right foot, Type II Diabetes Mellitus, essential primary hypertension, hyperlipidemia, and glaucoma. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #60 had highly impaired vision. The resident had moderate cognitive impairment. The resident was independent with bed mobility but needed limited assistance with one-person assistance for transfers and toileting. The resident required extensive assistance with one-person assistance for dressing, bathing and personal hygiene. The resident was not steady but able to stabilize without staff assistance while moving from a seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet, and surface to surface transfers. The resident had a lower extremity impairment on one side due to drop foot of his right foot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 9 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of care plan dated 01/08/18 revealed the care plan had not been revised. The care plan did not include a fall intervention of wearing non-skid socks at all times. Review of Progress Notes dated 07/21/19 revealed the physician was notified of a fall via fax. Review of fall investigation revealed Resident #60 had a fall on 07/21/19. The resident was found on the floor sitting on his buttocks at 8:30 AM. The resident was noted to have socks on that did not have grippers. The fall intervention was that resident would wear non slip socks at all times. Interview with Resident #60 and the resident's sister on 08/19/19 at 5:33 P.M. revealed the resident had at least two falls that happened during the night while trying to get to the bathroom unassisted. The resident and his sister indicated the resident was almost completely blind. Observation of Resident #60 on 08/21/19 at 9:01 A.M. revealed the resident was in bed. The resident had wool socks on that did not have any grippers. The resident indicated he would wear any socks that the aides put on him. Observation of Resident #60 on 08/21/19 at 2:53 PM revealed resident laying in bed. The resident was wearing the same wool socks as this morning. The socks did not have grippers on them. The resident stated he would not mind wearing non-slip socks. Interview with Registered Nurse (RN) #141 on 08/21/19 at 3:00 P.M., confirmed Resident #60 was not wearing non-slip socks. RN #141 verified with the resident that he would wear non-skid socks if the aide dressed him in them. RN #141 agreed to get non-skid socks for the resident. Interview with the DON on 08/22/19 at 11:15 A.M. confirmed Resident #60's care plan had not been updated to reflect the additional fall intervention of wearing non-skid socks at all times as indicated on the fall investigation completed on 07/21/19. 5. Review of the electronic medical chart for Resident #77 revealed an admission date of 06/21/19 with the following diagnoses: other fatigue, chronic obstructive pulmonary disease (COPD), essential hypertension, other sequelae of other cerebrovascular disease, and hyperlipidemia. Review of quarterly MDS 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. The resident was totally dependent on staff to complete all activities of daily living. The resident was non-ambulatory and used a geri chair for mobility. Review of Resident #77's care plan dated 06/28/19 revealed the care plan had not been revised following the resident's fall. The care plan did not include the fall interventions of a low bed with mats. Review of the fall investigation dated 07/12/19 revealed Resident #77 was found on the floor beside the bed with urine all over the floor because the resident's depends were pulled toward the bed when the resident slid off of the bed. The fall intervention was a low bed with mats. Review of physician's orders dated 07/14/19 revealed an order for a floor mat for safety. Interview with Resident #77 on 08/19/19 at 2:57 P.M. revealed the resident had slipped out of bed a couple of times approximately one month ago. The resident denied having any injuries following the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 10 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some falls. The resident indicated the nursing aide found the resident on the floor both times. The resident stated she had a pillow on the right side of the bed to help prevent the resident from sliding out of the bed. A floor mat was observed in front of the bed and the hospital bed was raised up. Observation of Resident #77 on 08/20/19 at 3:04 P.M. revealed the resident in her room sitting in a geri chair. A floor mat was observed in place next to the hospital bed. The resident was wearing non skid socks. The resident's bed was raised and not in a low position. Observation of Resident #77 on 08/21/19 at 8:48 A.M. revealed the resident laying in bed. The hospital bed was raised up and not in a low position. The resident was wearing non-skid socks. A floor mat was observed on the floor by the bed. Interview with LPN #155 on 08/21/19 at 10:47 A.M. confirmed Resident #77's bed was not in the lowest position. The nurse lowered the bed at the time of the interview. Interview with the Director of Nursing (DON) on 8/22/19 at 10:52 A.M. confirmed the resident should have a low bed due to recent falls. The DON reviewed the resident's fall investigations and care plan and confirmed the care plan had not been revised to include the intervention of a low bed. 6. Review of Resident #87's electronic medical chart revealed an admission date of 01/08/19 with the following diagnoses: personal history of traumatic brain injury, moderate protein-calorie malnutrition, anxiety disorder, opioid dependence-in remission, unspecified convulsions, hydrocephalus, and bipolar disorder. Review of physician's orders dated 02/20/19 revealed an order for a regular diet, pureed by mouth diet for each meal at lunch and dinner with one pureed entree and thin liquids with supervised mealtimes only for diet. Review of care plan dated 09/11/18 revealed several entries related to altered nutrition status due to tube feeding twice daily. Review of progress notes dated 07/31/19 indicated a general, regular diet, pureed texture. Water flushes 250 cc every six hours. The resident tolerated an oral diet and was ambulating more. Observation and interview with Resident #87 on 08/21/19 at 8:55 A.M. revealed the resident laying in bed watching television. The resident indicated he ate breakfast by mouth and no longer needed tube feeds. Interview with the Registered Dietitian (RD) on 08/21/19 at 2:07 P.M. confirmed the resident was no longer receiving any tube feeds. The feeding tube was only in place in case the resident started to lose weight again. The resident had the feeding tube removed prior to a previous discharge to home and resident returned to the facility after experiencing a 30 pound weight loss and needed the feeding tube placed again. The RD was monitoring the resident's weights weekly and indicated the resident had been stable for a little bit of time but remained at risk for nutrition. Interview with the DON on 08/22/19 at 11:25 A.M. confirmed Resident #87's care plan had not been revised after tube feeds had been discontinued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 11 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview the facility failed to provide assistance with eating during lunch meal. This affected one (#76) of 13 residents observed who were eating in the first floor dining room during lunch. The facility census was 120. Residents Affected - Few Findings include: Review of Resident #76's electronic medical record revealed an admission date of 12/21/16 with the following diagnoses: Parkinson's Disease, dementia in other diseases classified elsewhere without behavioral disturbance, altered mental status, unspecified psychosis not due to a substance or known physiological condition, endocarditis, major depressive disorder, and essential hypertension. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed the resident had severely impaired cognition. The resident required supervision with eating for set up only. No swallowing or nutrition concerns were noted. Review of Resident #76's care plan dated 01/19/18 revealed the resident was a potential nutritional risk. On 07/11/18, the resident was admitted to hospice services with a diagnosis of Parkinson's Disease. The resident needed assistance with eating. Review of Resident #76's monthly weights revealed the resident had a weight loss from 144 pounds on 07/11/19 to 136 pounds on 08/08/19. Observation of Resident #76 during lunch meal on 08/19/19 at 11:52 A.M. revealed the resident attempted to take a drink of lemonade. The resident was not able to bring the glass to his mouth and set the cup back down on the table. The resident was observed sitting at the table with his left arm bent on the table and his left hand on his forehead. Observation of Resident #76 on 08/19/19 at 12:01 P.M. revealed the resident eating pasta with his fingers. The resident was not using the silverware provided. The resident had a tremor noted to his left hand. Observation of Resident #76 on 08/19/19 at 12:03 P.M. revealed the resident continued to attempt to eat the pasta with his fingers. The resident attempted to bring the pasta to his mouth and the pasta fell from his fingers and dropped on the floor in front of him. No staff were present to assist the resident. Observation of Resident #76 on 08/19/19 at 12:12 P.M. revealed the resident picked up the spoon and put pasta on it. The resident attempted to take a bite of pasta from the spoon and the pasts dropped on the table in front of him. No staff were observed assisting the resident. Observation of Resident #76 on 08/19/19 at 12:19 P.M. revealed the resident dipped the spoon into the glass of lemonade for an ice cube. The resident attempted to bring the ice cube to his mouth and the ice cube dropped off the spoon onto the table in front of him. Interview with State Tested Nursing Assistant (STNA) #175 on 08/19/19 at 12:21 P.M. confirmed Resident #76 usually received assistance with eating but staff had been too busy to provide needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 12 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0677 assistance today. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 13 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 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. Based on record review and staff interview the facility failed to properly monitor resident behaviors following a documented incident. This affected one (#87) of one resident reviewed for behavior changes. The facility census was 120. Findings include: Review of Resident #87's electronic medical chart revealed an admission date of 01/08/19 with the following diagnoses: personal history of traumatic brain injury, moderate protein-calorie malnutrition, anxiety disorder, opioid dependence-in remission, unspecified convulsions, hydrocephalus, and bipolar disorder. Review of physician's orders dated 07/22/19 revealed Seroquel tablet 50 milligram (mg) give one tablet via peg tube at bedtime for bipolar disorder. Review of Resident #87's care plan dated 09/11/18 revealed the resident was at risk for adverse reactions and side effects due to receiving psychotropic medication related to bipolar disorder. The interventions included document mood and behavior changes when they occur, monitor and record the occurrence of targeted behaviors including violence or aggression towards staff or others and document per facility protocol. Review of Nurse's progress notes dated 07/03/19 revealed a family member was visiting a loved one last night on this unit and reported this resident followed her and her granddaughter to the double doors where she was trying to exit. They turned and went back to the elevator to try to get on it without this resident but he followed her there also. The elevator doors opened and the visitor stepped on the elevator while another nursing aide called to the resident to come back but he would not. He reached out and grabbed the visitor by her hair and yanked her backward then put his hand around her throat and held her against the door refusing to let go. The granddaughter was screaming The nurse aide called out to the nurse, who was in the medication room, and the nurse intervened. The resident let go of the visitor and the visitors were able to exit the building. The incident was reported by the nurse and the aide on duty to the nurse who wrote the progress note. Interview with Licensed Practical Nurse (LPN) #155 on 08/21/19 at 2:25 P.M. revealed the nurse worked regularly on the locked unit with the resident. The LPN indicated she was not aware of any aggressive or violent incidents involving the resident. The LPN stated the resident had never acted aggressively toward the staff or other residents to her knowledge. Interview with the resident's physician on 08/21/19 at 2:30 P.M. revealed the physician was not aware of any aggressive or violent incidents involving the residents. The physician indicated he was on vacation for a week in the month of July. The physician stated due to the resident's brain injury, behaviors could be unpredictable and could change without warning. The physician stated the behavior he witnessed was mostly inappropriate language used by the resident. The physician denied the resident had ever acted aggressively toward staff or other residents to his knowledge. Interview with the unit manager, LPN #59, on 08/21/19 at 4:02 P.M. revealed the LPN was the unit manager at the time of the incident. LPN #59 denied being notified of the incident by any staff. LPN #59 indicated the resident had never acted aggressively toward the staff or other residents to her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 14 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0740 knowledge. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 08/21/19 at 4:03 P.M. revealed the DON was able to confirm the incident had occurred as reported in the nurse's note by the nurse on duty, LPN #52. LPN #52 confirmed to the DON she did not report the incident to administration. The DON indicated she was unaware of the incident. The DON stated had LPN #52 reported the incident, the resident would have been placed on one to one supervision until the resident's agitation and aggression was resolved. The physician would have been notified and the resident's behaviors would have been closely monitored following the incident. The DON confirmed no interventions were put in place following the incident due to not being aware it had occurred. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 15 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and staff interview the facility failed to provide needed adaptive equipment for eating. This affected one (#23) of 13 residents observed in the first floor dining room. The facility census was 120. Residents Affected - Few Findings include: Review of Resident #23's electronic medical record revealed an original admission date of 05/21/18 and a readmission date of 07/19/19 with the following diagnoses: unspecified intracranial injury with loss of consciousness of unspecified duration, malignant neoplasm of unspecified testis, secondary malignant neoplasm of unspecified lung, unspecified cirrhosis of liver, dysphagia-oropharyngeal phase, epilepsy, facial weakness, bipolar disorder, major depressive disorder-severe with psychotic symptoms, anxiety disorder, diabetes mellitus due to underlying condition without complications, personal history of malignant neoplasm of bladder, and vitamin deficiency. Review of physician's orders dated 08/2019 revealed an order for a regular diet, regular texture, nectar consistency, a nosey cup at meal times per speech therapy, and a red non-slip scoop plate at meals and good grip bendable utensils per speech therapy. Review of the care plan dated 10/04/18 revealed the resident had a deficit in activities of daily living, interventions included eating as set up and supervision, extensive to feed if does not finish meal, red non-slip scoop plate at meals and good grip bendable utensils per speech therapy. Observation of Resident #23 on 08/19/19 at 12:07 P.M. revealed the resident attempted to take a bite of pasta. The pasta dropped into the resident's lap. No staff were assisting the resident. The resident was using adaptive silverware but no adaptive plate. Observation of Resident #23 on 08/19/19 at 12:10 P.M. revealed the resident attempted to take a bite of red jello with an adaptive spoon from a small glass container. The resident was not able to scoop the jello onto the spoon to take a bite. Observation of Resident #23 on 08/19/19 at 12:11 P.M. revealed the resident attempted to scoop the jello again onto the spoon. The resident was not able to do this and spilled the container of jello on the table. The jello then fell onto the table and into the resident's lap. The resident started using the spoon to eat the jello off the table. No staff assisted the resident. Observation of Resident #23 on 08/19/19 at 12:17 P.M. revealed an aide was cleaning up the jello from the table. The resident stated they were sorry. The aide offered to serve more jello to the resident but the resident declined. Observation of Resident #23 on 08/19/19 at 12:20 P.M. revealed the resident left the dining room. On the residents tray was 3/4 of a breadstick and a full bowl of pasta left uneaten. Interview with State Tested Nursing Assistant (STNA) #175 on 08/19/19 at 12:31 P.M. confirmed the resident should have had a special plate to assist the resident with eating but it was not brought for the resident to use today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 16 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and facilities policy review the facility failed to follow infection control practices during a pressure ulcer wound dressing change. This affected one Resident (#81) of three residents reviewed for pressure ulcers. Furthermore, the facility failed to maintain effective urinary catheter infection control procedures when they had the urinary catheter bag above the level a residents bladder. This affected one Resident (#99) of two reviewed for catheters. The facility identified three Residents (#86, #99, and #163) who had indwelling catheters. The facility census was 120. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 04/10/18 with diagnoses including ischemic cardiomyopathy, diabetes mellitus, chronic kidney disease, and osteoarthritis. Review of physician orders dated 08/2019 revealed to cleanse coccyx with normal saline or wound cleanser, apply honey paste to wound bed then cover with calcium alginate and cover with foam dressing every day shift. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had some moderate cognitive deficits and had a stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed, slough may be present but does not obscure the depth of tissue loss) present upon admission. Review of the care plan revealed Resident #81 had pressure ulcer to coccyx and intervention included treatment per order. Observation was conducted on 08/20/19 at 2:11 P.M. of Licensed Practical Nurse (LPN) #10 do wound care for Resident #81. LPN #10 washed her hands, applied gloves, and removed the old dressing from Resident #81's coccyx and then removed her gloves, applied new gloves, and then proceeded to clean the area with normal saline, patted dry, and then she placed medihoney on her same gloved finger she cleansed the wound with. She took the gloved index finger inside the open area to fill with medihoney, next she covered the area with calcium alginate and covered the area with allevyn foam dressing. She removed her gloves and washed her hands after treatment. LPN #10 did not wash her hands after removing the gloves the first time, nor after cleansing the area. She did not use clean gloves or an applicator to apply the medihoney inside the wound bed. Interview was conducted on 08/21/19 at 10:17 A.M. with the Director of Nursing and she stated per policy staff was to use clean precautions when attending to wounds which included to wash hands, apply gloves, remove dressing, wash hands and change gloves. She verified hands should always be washed after removing gloves. She verified nurses should not have applied medihoney with her gloved finger into the wound bed with the same gloves she cleaned the wound with. Review of facilities Wound Care Treatment Policy dated 08/13/09 revealed the purpose was to identify correct procedure to clean wound and apply dressing. Licensed nursing staff are to use standard clean precautions when attending to resident wounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 17 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facilities Handwashing and Hand Hygiene Policy dated 08/21/19 revealed the purpose was to provide guidelines for effective handwashing and hygiene techniques that will aid in the prevention of the transmission of infections. Appropriate handwashing with antimicrobial and water must be performed before and after direct contact with residents, after contact with blood, body fluids, secretions, or non intact skin, and after removing gloves. The use of gloves does not replace handwashing. If hands are not visible soiled, use an alcohol based hand rub for handling clean or soiled dressings, gauze pads, etc., after contact with residents intact skin, after handling used dressings, and after removing gloves. 2. Record review of Resident #99 revealed an admission date of 07/19/19 with diagnoses of complete lesion of cervical spinal cord at cervical vertebrae five level, acute and chronic respiratory failure, acute osteomyletitis, paraplegia, moderate protein calorie malnutrition, tracheostomy, gastrostomy, neurogenic bowel, neuromuscular dysfunction of the bladder, hypotension, dysphagia, insomnia, anxiety disorder, and colostomy status. Review of the 30 day MDS assessment dated [DATE] revealed the resident was cognitively intact and required total dependence of two people for bed mobility, transfer, locomotion on and off unit, dressing, toilet use, bathing, and personal hygiene. The resident used a wheelchair to aid in mobility, and had an indwelling catheter and an ostomy. Observation on 08/19/19 at 2:13 P.M. revealed Resident #99 sitting his room in a geriatric chair with his feet elevated and his indwelling urinary catheter bag sitting between his legs even or higher than his bladder. Interview with Resident #99 on 08/19/19 at the time of the observation revealed staff had brought him back from smoking about 1:30 P.M. and no staff had placed the catheter bag in the correct draining position. Interview with State Tested Nurse Aide (STNA) #101 on 08/19/19 at 2:16 P.M. verified Resident #99's catheter drainage bag was sitting between his legs even or higher than his bladder. Review of a facility policy titled Indwelling Catheter Bags dated 12/27/10 revealed to encourage Resident to keep the catheter bag below the bladder for drainage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 18 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility failed to provide a sanitary and comfortable environment for residents as all carpeted areas on all floors in the facility were stained and worn. This had the potential to affect all 120 residents residing in the facility. Furthermore, the facility failed to ensure walls were in good repair in one resident's room. This affected one Resident (#54) who's wall was scraped. The facility census was 120. Findings include: Multiple observations were conducted of all three floors of the facility during the annual survey from 08/19/19 through 08/22/19 and observed worn down carpeted areas with multiple dark colored stains. An observation was conducted on 08/22/19 at 3:07 P.M. of Resident #54's wall behind her bed and noted multiple scraped areas. Interview was conducted on 08/22/19 at 3:07 P.M. with Resident #54. She stated her wall was awful and that it was like that when she moved into the room. She denied that she had scraped the wall. Interview was conducted on 08/22/19 at 4:00 P.M. with Maintenance Staff #168 and he verified the carpets throughout the facility were very soiled with stains that would not come up when cleaned repeatedly. Maintenance Staff #168 also verified the carpet was very worn and needed replaced. He verified Resident #54's wall was scraped up and needed patched and repainted. He stated it was the beds that get moved into the walls. Interview was conducted on 08/22/19 at 4:03 P.M. with the Administrator and he also verified the carpets on all three floors were in need of repair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 19 of 20 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facilities policy review the facility failed to maintain an effective pest control program so that the facility was free of flies. This had the potential to affect 38 residents residing on the first floor. The facility census was 120. Residents Affected - Some Findings include: Observation was made on 08/19/19 at 11:05 A.M. of the first floor and noted two fly traps hanging from the ceiling of Resident #86's room with one by her bed and one by the doorway. She stated flies were bad and that her husband had hung up the strips. There were two flies flying around her bed. Interview was conducted on 08/19/19 at 11:23 A.M. with Resident #59 and he stated he had flies in his room. Observation was made on 08/19/19 at 11:38 A.M. of Resident #6 and he was swatting flies in his room with a fly swatter. He stated the flies were bad. Interview also conducted with Resident #6's room mate, Resident #4, and he stated the flies were bad right now. Observation was made on 08/20/19 at 9:16 A.M. of Resident #19 and a fly was on his bed on top of his blankets and roommate (Resident #62) stated he had already killed two flies this morning in their room. Interview was conducted on 08/20/19 at 10:00 A.M. with Resident #9 and he stated the flies were terrible. Interview was conducted on 08/22/19 at 4:00 P.M. with Maintenance Staff #168 and he verified there were flies on the first floor due to the door at the end of the hall was constantly being opened by residents and staff due to them going into the smoking area. He stated they have hung two bug lights on the first floor and verified one was not lit up and stated it may need a new bulb. Review of facilities Pest Control Policy dated 08/13/09 revealed the purpose was to prevent pests in the facility. Pest control company comes in monthly and as needed to treat for pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 20 of 20

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Citations

22 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0925GeneralS&S Epotential for harm

    F925 - Maintain an effective pest control program so that the facility is free of

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0921GeneralS&S Fpotential for harm

    F921 - Other Environmental Conditions

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  • 0131GeneralS&S Epotential for harm

    Meet requirements for sections of health care facilities separated by fire resistive construction.

  • 0225GeneralS&S Epotential for harm

    Have stairways and smokeproof enclosures used as exits that meet safety requirements.

  • 0341GeneralS&S Epotential for harm

    Install a fire alarm system that can be heard throughout the facility.

  • 0351GeneralS&S Epotential for harm

    Install an approved automatic sprinkler system.

  • 0353GeneralS&S Fpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0039GeneralS&S Cno actual harm

    Conduct testing and exercise requirements.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0655GeneralS&S Dpotential for harm

    F655 - Comprehensive Person-Centered Care Planning

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  • 0363GeneralS&S Epotential for harm

    Install corridor and hallway doors that block smoke.

  • 0521GeneralS&S Epotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0712GeneralS&S Fpotential for harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

  • 0761GeneralS&S Fpotential for harm

    F761 - Labeling of Drugs and Biologicals

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  • 0913GeneralS&S Epotential for harm

    F913 - Have direct access to an exit corridor;

    Ensure operating rooms are properly protected and written records are maintained and available for inspection.

  • 0914GeneralS&S Fpotential for harm

    F914 - Be designed or equipped to assure full visual privacy for each

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  • 0657GeneralS&S Epotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0740GeneralS&S Dpotential for harm

    F740 - Behavioral health services

    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  • 0810GeneralS&S Dpotential for harm

    F810 - Assistive devices

    Provide special eating equipment and utensils for residents who need them and appropriate assistance.

FAQ · About this visit

Common questions about this visit

What happened during the August 22, 2019 survey of WESTMORELAND PLACE?

This was a inspection survey of WESTMORELAND PLACE on August 22, 2019. The surveyor cited 22 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WESTMORELAND PLACE on August 22, 2019?

Yes, 22 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Make sure there is a pest control program to prevent/deal with mice, insects, or other pests."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.