Health inspection·October 31, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident medications were administered as ordered by the physician. This affected two (Resident #22 and Resident #28) of five residents reviewed for unnecessary medications. The facility census was 34 residents. Findings include: 1.Review of the medical record for Resident #22 revealed an admission date of 08/19/2019 with diagnoses including dementia with psychotic disturbance, diabetes mellitus type two, adult failure to thrive, peripheral vascular disease, insomnia, depression, anxiety and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 08/29/24 revealed the resident #22 had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.) Review of the pharmacy recommendation for Resident #22 dated 10/07/24 revealed the pharmacist recommended the resident's dose of Celexa be reduced from 20 milligrams (mg) daily to 10 mg daily. The attending physician signed in agreed and the order was written. Review of the physician progress note for Resident #22 dated 10/14/24 revealed the had been crying uncontrollably after gradual dose reduction. The physician's plan was to increase the Celexa back to 20 mg. Review of the nursing progress notes for Resident #22 dated 10/14/24 revealed the resident was tearful when the attending physician was in the facility and the physician gave an order for Celexa 20 mg. Review of the physician's orders for Resident #22 for October 2024 revealed an order dated 10/07/24 for Celexa 10 mg daily and an order dated 10/14/24 for Celexa 20 mg daily. Review of the Medication Administration Record (MAR) for Resident #22 dated October 2024 revealed the resident received two doses of Celexa 10 mg and 20 mg from 10/14/24 to 10/30/24. Interview on 10/30/24 at 1:55 P.M. with Unit Manager (UM) #52 confirmed Resident #22 received an excessive dose of Celexa with staff administering a 10 mg tablet and a 20 mg tablet daily from 10/14/24 to 10/30/24. Unit Manager #52 confirmed when the physician gave the order on 10/14/24 to increase the Celexa to 20 mg, the order for the 10 mg tablet should have been discontinued. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 366338 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 10/31/2024 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)