Health inspection·November 6, 2023

F 0550 urinary catheter collection bag was not covered for privacy and urine was visible from the hallway. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #15 revealed an initial admission date of 08/07/23 with the latest readmission of 10/26/23 with diagnoses including periprosthetic fracture around internal prosthetic right knee joint, removal of internal fixation device, diabetes mellitus, emphysema, protein calorie malnutrition, retention of urine, seizures, neuromuscular dysfunction of bladder, urinary tract infection, sepsis due to E-coli, hypertension, gout, gastro-esophageal reflux disease, major depressive disorder and visual loss. Residents Affected - Some Review of the plan of care dated 08/14/23 revealed the resident was admitted to the facility with an indwelling urinary catheter in place for neurogenic bladder. Interventions included size 16 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's state optional MDS assessment dated [DATE] revealed the resident had no cognitive impairment. The resident required extensive assistance of two staff for toilet use. Review of the monthly physician orders for November 2023 identified orders dated `0/27/23 indwelling urinary catheter to straight drain, maintain and provide indwelling urinary catheter care every shift, change indwelling urinary catheter and drainage bag as a unit for blockage leakage or malfunction and maintain indwelling urinary catheter size 16 FR with 10 ml balloon to straight drain for diagnosis of neurogenic bladder. Observation on 11/06/23 at 8:55 A.M. of Resident #15 revealed the resident's indwelling urinary catheter collection bag was not contained in a privacy bag and urine was visible from the hallway. Interview with State Tested Nursing Assistant (STNA) #102 verified the indwelling urinary catheter collection bag was not covered for privacy and urine was visible from the hallway at the time of the observation. 3. Review of the medical record for Resident #34 revealed an initial admission date of 08/19/23 with the diagnoses including ataxia following cerebral infarction, aphasia, dysphagia, dementia, hypertension, diabetes mellitus, retention of urine, hypothyroidism, neuromuscular dysfunction of bladder and insomnia. Review of the plan of care dated 08/22/23 revealed the resident was admitted with an indwelling urinary catheter in place for neurogenic bladder, voiding trial attempted at hospital without success. Interventions included size 18 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two staff for toilet use. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366338 If continuation sheet Page 2 of 7 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 366338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE National Church Residences Chillicothe 142 University Drive 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 0550 bowel. Level of Harm - Minimal harm or potential for actual harm Review of the monthly physician orders for November 2023 identified orders dated 08/19/23 indwelling urinary catheter to straight drain, maintain and provide indwelling urinary catheter care every shift, 10/12/23 maintain indwelling urinary catheter size 18 FR with 10 ml balloon to straight drain for diagnoses of neurogenic bladder and 11/03/23 change indwelling urinary catheter and drainage bag as a unit for blockage, leakage or malfunction. Residents Affected - Some Observation on 11/06/23 at 9:28 A.M. of Resident #34 revealed the resident was sitting up on the side of her bed. The resident's indwelling urinary collection bag was laying on the floor with no privacy cover and urine was visible from the hallway. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag had no privacy cover and urine was visible from the hallway. 4. Review of the medical record for Resident #41 revealed an initial admission date of 10/20/23 with the diagnoses including nonalcoholic steatohepatitis, palliative care, Parkinsonism, diabetes mellitus, hypertension, gastro-esophageal reflux disease, and neuromuscular dysfunction of bladder. Review of the clinical admission assessment dated [DATE] revealed the resident was alert and oriented. Review of the functional abilities and goals dated 10/23/23 revealed the resident required maximal assistance with toilet use. Review of the plan of care dated 10/23/23 revealed the resident was admitted with indwelling urinary catheter in place for neurogenic bladder. Interventions included size 16 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's MDS list revealed the comprehensive MDS dated [DATE] revealed the assessment was not completed. Review of the monthly physician orders for November 2023 identified orders dated 10/20/23 indwelling urinary catheter to straight drain, maintain and provide catheter care every shift, change indwelling urinary catheter [NAME] as a unit for blockage, leakage or malfunction as needed and maintain indwelling urinary catheter size 16 FR with 30 ml balloon to straight drain for diagnoses of neurogenic bladder. Observation on 11/06/23 at 9:30 A.M. revealed Resident #41's indwelling urinary catheter bag had no privacy cover and urine was visible from the hallway. Further observation revealed the indwelling urinary catheter bag was hanging on the side rail above the resident's bladder. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag had no privacy cover and urine was visible from the hallway. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366338 If continuation sheet Page 3 of 7 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 366338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE National Church Residences Chillicothe 142 University Drive 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 0550 Level of Harm - Minimal harm or potential for actual harm 5. Review of the medical record for Resident #5 revealed an initial admission date of 04/19/23 with the latest readmission of 10/10/23 with diagnoses including severe protein calorie malnutrition, gastrostomy, chronic respiratory failure, diabetes mellitus, congestive heart failure, chronic kidney disease, peripheral venous insufficiency, urinary tract infection, major depressive disorder, atrial fibrillation, obstructive and reflux uropathy, hypertension, gout, carpal tunnel syndrome, anemia and osteoarthritis. Residents Affected - Some Review of the plan of care dated 05/22/23 revealed the resident had an indwelling urinary catheter in place for urinary obstruction. Interventions included size 14 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two staff for toilet use. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. Review of the monthly physician orders for November 2023 identified orders dated 09/21/23 indwelling urinary catheter to straight drain, maintain and provide catheter care every shift, change indwelling urinary catheter [NAME] as a unit for blockage, leakage or malfunction as needed and maintain indwelling urinary catheter size 14 FR with 30 ml balloon to straight drain for diagnoses of neurogenic bladder. Observation on 11/06/23 at 9:34 A.M. of Resident #5 revealed the resident's indwelling urinary catheter had no privacy bag and urine was visible from the hallway. Further observation revealed the resident's indwelling catheter bag was hanging on the bed side rail above the resident's bladder. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag had no privacy cover and urine was visible from the hallway. Review of the facility policy titled, Catheter-Urinary Female and Male, last revised 03/19 revealed the indwelling catheter drainage bag was to be placed in a catheter bag cover. This deficiency represents non-compliance investigated under Complaint Number OH00147383. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366338 If continuation sheet Page 4 of 7 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 366338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE National Church Residences Chillicothe 142 University Drive 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to ensure three residents (#5, #34 and #41) indwelling urinary catheter collection bag was properly positioned to facilitate optimal drainage of urine. This affected three of seven residents reviewed for urinary catheter. The facility identified seven residents with indwelling urinary catheters. The facility census was 42. Findings Include: 1. Review of the medical record for Resident #34 revealed an initial admission date of 08/19/23 with the diagnoses including ataxia following cerebral infarction, aphasia, dysphagia, dementia, hypertension, diabetes mellitus, retention of urine, hypothyroidism, neuromuscular dysfunction of bladder and insomnia. Review of the plan of care dated 08/22/23 revealed the resident was admitted with an indwelling urinary catheter in place for neurogenic bladder, voiding trial attempted at hospital without success. Interventions included size 18 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's comprehensive minimum data set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two staff for toilet use. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the monthly physician orders for November 2023 identified orders dated 08/19/23 indwelling urinary catheter to straight drain, maintain and provide indwelling urinary catheter care every shift, 10/12/23 maintain indwelling urinary catheter size 18 FR with 10 ml balloon to straight drain for diagnoses of neurogenic bladder and 11/03/23 change indwelling urinary catheter and drainage bag as a unit for blockage, leakage or malfunction. Observation on 11/06/23 at 9:28 A.M. of Resident #34 revealed the resident was sitting up on the side of her bed. The resident's indwelling urinary collection bag was laying on the floor with no privacy cover and urine was visible from the hallway. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag was laying on the floor preventing optimal drainage of urine. 2. Review of the medical record for Resident #41 revealed an initial admission date of 10/20/23 with the diagnoses including nonalcoholic steatohepatitis, palliative care, Parkinsonism, diabetes mellitus, hypertension, gastro-esophageal reflux disease, and neuromuscular dysfunction of bladder. Review of the clinical admission assessment dated [DATE] revealed the resident was alert and oriented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366338 If continuation sheet Page 5 of 7 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 366338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE National Church Residences Chillicothe 142 University Drive 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the functional abilities and goals dated 10/23/23 revealed the resident required maximal assistance with toilet use. Review of the plan of care dated 10/23/23 revealed the resident was admitted with indwelling urinary catheter in place for neurogenic bladder. Interventions included size 16 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's MDS list revealed the comprehensive MDS dated [DATE] revealed the assessment was not completed. Review of the monthly physician orders for November 2023 identified orders dated 10/20/23 indwelling urinary catheter to straight drain, maintain and provide catheter care every shift, change indwelling urinary catheter [NAME] as a unit for blockage, leakage or malfunction as needed and maintain indwelling urinary catheter size 16 FR with 30 ml balloon to straight drain for diagnoses of neurogenic bladder. Observation on 11/06/23 at 9:30 A.M. revealed Resident #41's indwelling urinary catheter bag had no privacy cover and urine was visible from the hallway. Further observation revealed the indwelling urinary catheter bag was hanging on the side rail above the resident's bladder. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag was hanging above the bladder preventing optimal draining of urine. 3. Review of the medical record for Resident #5 revealed an initial admission date of 04/19/23 with the latest readmission of 10/10/23 with diagnoses including severe protein calorie malnutrition, gastrostomy, chronic respiratory failure, diabetes mellitus, congestive heart failure, chronic kidney disease, peripheral venous insufficiency, urinary tract infection, major depressive disorder, atrial fibrillation, obstructive and reflux uropathy, hypertension, gout, carpal tunnel syndrome, anemia and osteoarthritis. Review of the plan of care dated 05/22/23 revealed the resident had an indwelling urinary catheter in place for urinary obstruction. Interventions included size 14 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two staff for toilet use. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. Review of the monthly physician orders for November 2023 identified orders dated 09/21/23 indwelling urinary catheter to straight drain, maintain and provide catheter care every shift, change indwelling urinary catheter [NAME] as a unit for blockage, leakage or malfunction as needed and maintain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366338 If continuation sheet Page 6 of 7 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 366338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE National Church Residences Chillicothe 142 University Drive 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indwelling urinary catheter size 14 FR with 30 ml balloon to straight drain for diagnoses of neurogenic bladder. Observation on 11/06/23 at 9:34 A.M. of Resident #5 revealed the resident's indwelling urinary catheter had no privacy bag and urine was visible from the hallway. Further observation revealed the resident's indwelling catheter bag was hanging on the bed side rail above the resident's bladder. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag was hanging above the bladder preventing optimal draining of urine. Review of the facility policy titled, Catheter-Urinary Female and Male, last revised 03/19 revealed the are to be hung below the level of the bladder and do not hang on bed rail. This deficiency represents non-compliance investigated under Complaint Number OH00147383. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366338 If continuation sheet Page 7 of 7