National Church Residences Chillicothe

Based on observations, interviews , record review and review of facility policy and procedure, the facility failed to ensure post fall interventions were in place for one resident (#14) out of three residents (#12, #14 and #22) reviewed for falls. The census was 34. Findings include:Review of medical record for Resident # 14 revealed readmission date of 12/9/25 with diagnoses including Alzheimer's disease, dementia , Type tTo Diabetes, chronic kidney disease and multiple sclerosis .Resident #14's quarterly Minimum Data Systems (MDS) revealed a Brief Interview of Mental Status BIMS score of six indicating severe cognitive deficits. Her care plan last updated on 03/16/26 revealed she was dependent on one to two staff members for activities of daily living; she used a wheelchair for transportation.Review of the facility's Incident Report log from 04/08/26 to 04/22/26 revealed Resident #14 experienced an unwitnessed falls on 04/08/26, 04/17/26 and 04/19/26.Review of Resident #14's nurse progress notes dated 11/01/26 to 04/22/26 revealed the falls occurred during multiple times of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were completed and updated to reflect a new qualifying diagnosis. This affected two (#5 and #38) of two residents reviewed for PASARR accuracy. The facility census was 36.Findings include: 1. Review of Resident #38's medical record revealed an admission date of 01/09/24. Diagnoses included acute and chronic respiratory failure with hypoxia, congestive heart failure, type II diabetes, atrial fibrillation, mild cognitive impairment of unknown etiology, dysphagia, generalized anxiety disorder, drug induced subacute dyskinesia, major depressive disorder, and fibromyalgia. Further review revealed a diagnoses with onset date of 09/26/23 of unspecified psychosis not due to a substance or known physiological condition, and fibromyalgia. Review of Resident #38's Minimum Data Set (MDS) assessment dated [DATE] revealed anxiety disorder, depression (other than bipolar), and psychotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to develop a plan of care for residents with diagnoses of Alzheimer's disease and dementia. This affected one (#5) of 17 residents reviewed for care plans. The facility census was 36.Findings include:Record review for Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses included seizures, aortic valve stenosis, chronic kidney disease, osteoarthritis, Alzheimer's disease, dementia, secondary Parkinsonism, convulsions, psychotic disorder, anxiety, and psychotic disorder with delusions and hallucinations. Further review of the resident's diagnoses revealed Alzheimer's disease and dementia were added as new diagnoses on 12/01/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition.Review of Resident #5's current comprehensive care plan, last revised on 12/17/25, revealed there was no care plan put into place to address Resident #5's care needs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and resident family interview, and staff interview, the facility failed to provide care and services for the prompt treatment of a urinary tract infection. This affected one (#14) of three residents reviewed for urinary tract infections. The facility census was 36.Findings include:Record review for Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses included left femur fracture, anemia, acute respiratory failure, chronic kidney disease, falls, congestive heart failure, obesity, depression, gastro-esophageal reflux disease, and polyneuropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had no cognitive impairment. The resident was also assessed to be occasionally incontinent of bladder and frequently incontinent of bowel.Review of a nursing note dated 12/22/25 at 12:17 P.M. revealed Resident #14 began complaining of dysuria (painful urination). A urinalysis with culture and sensitivity was documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview the facility failed to ensure medications were administered as ordered to maintain a medication error rate less than five percent (%). A total of three medication errors were observed out of 38 opportunities for a medication error rate of 7.89%. This affected three (#8, #20, and #34) of five residents observed during medication administration. The census was 36. Findings Include:1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, cirrhosis of the liver, acquired absence of the right leg above the knee, and chronic kidney disease, stage three. Review of Resident #8's current physician orders revealed an order for insulin aspart three (3) units subcutaneously (SQ) via injector pen before meals with instructions to hold for a blood glucose level less than 200 milligrams per deciliter (mg/dL).Observation of medication administration on 12/31/25 at 8:45 A.M. revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure medications were administered as ordered resulting in significant medication errors. This affected two (#8 and #34) of five residents observed during medication administration. The census was 36. Findings Include:1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, cirrhosis of the liver, acquired absence of the right leg above the knee, and chronic kidney disease, stage three. Review of Resident #8's current physician orders revealed an order for insulin aspart three (3) units subcutaneously (SQ) via injector pen before meals with instructions to hold for a blood glucose level less than 200 milligrams per deciliter (mg/dL).Observation of medication administration on 12/31/25 at 8:45 A.M. revealed Licensed Practical Nurse (LPN) #201 obtained Resident #8's blood glucose level with a reading of 245 mg/dL. LPN #201 then prepared…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received needed and routine dental services. This affected one (Resident #26) of one resident reviewed for dental services. The facility census was 34 residents. Findings include: Review of the medical record for Resident #26 revealed an admission date of 05/02/23 with diagnoses including paroxysmal atrial fibrillation, diabetes mellitus type two, hypertensive heart disease and depression. Review of the care plan for Resident #26 initiated 05/02/23 revealed it did not include a care plan for dental/oral care. Review of Minimum Data Set (MDS) assessment for Resident #26 dated 08/30/24 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs).) Review of the physician's orders for Resident #26 dated October 2024 revealed the resident received a regular diet with regular texture and thin liquids. Review of the medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure staff practiced proper infection control precautions during an outbreak of COVID-19. This had the potential to affect all 25 residents (#1, #3, #5, #6, #7, #11, #12, #13, #14, #15, #17, #18, #20, #21, #22, #24, #26, #28, #29, #30, #31, #32, #35, #36, and #42) who were negative for COVID-19 and resided on the same unit as Resident #10 and Resident #27. The census was 41. Findings include: Observation on 12/06/23 from 9:55 A.M. to 10:10 A.M. revealed State Tested Nursing Aide (STNA) #103 walking out of Resident #10 and Resident #27's room, who were on droplet isolation precautions due to having COVID-19. She removed all of her used personal protective equipment (PPE) except for her N95 respirator prior to walking out of their room. When she got out of their room, she took her N95 respirator off with her left hand, balled it up and placed it on a plastic cart. She placed a surgical mask on her face, took the used N95 respirator and disposed of it in the trash can near…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 five residents (#3, #5, #15, #34 and #41) indwelling urinary catheter collection bag was covered for privacy. This affected five of seven residents reviewed for indwelling urinary catheters. The facility identified seven residents with indwelling urinary catheters. The facility census was 42. Findings Include: 1. Review of the medical record for Resident #3 revealed an initial admission date of 01/20/23 with the latest readmission of 04/05/23 with diagnoses including chronic respiratory failure, atrial fibrillation, emphysema, hypertension, chronic kidney disease, anemia, basal cell carcinoma of skin of right upper limb, obstructive and reflux uropathy, osteoarthritis, hyperlipidemia and gastro-esophageal reflux disease. Review of the plan of care dated 01/23/23 revealed the resident was admitted to the facility with an indwelling urinary catheter in place for obstructive uropathy. Interventions included size…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and medical record review the facility failed to identify and monitor a resident's skin with regards to bruising and a discolored area. This affected one (Resident #04) of four sampled residents reviewed for skin conditions non-pressure. The facility census was 32. Findings include: Review of Resident #04's medical record revealed she was admitted on [DATE] with diagnoses that included: Parkinson's disease, type II diabetes with polyneuropathy, hypertension, hyperlipidemia, bipolar disease, anxiety, psychosis, restless legs, and overactive bladder. Review of Resident #04's quarterly Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #04 had minimal difficulty hearing, had a hearing aid, her speech was clear, she made herself understood, understands others, and her cognition was intact. Resident #04 had minimal depression, had no indicators of psychosis, had no behaviors, and did not reject care. Resident #04 required extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and medical record review the facility failed to provide treatment and services to a resident who had a decline in both urinary and bowel continence. This affected one resident (Resident #14) of two sampled residents reviewed for bowel and bladder incontinence. The facility census was 32. Findings include: Review of Resident #14's medical record revealed she was admitted on [DATE] with diagnoses that included: emphysema, atherosclerotic heart disease, type II diabetes with polyneuropathy, morbid obesity, hyperlipidemia, chronic respiratory failure, gastro-esophageal reflux, age related osteoporosis, and diverticulosis. Review of Resident #14's annual Minimum Data Set (MDS) dated [DATE] revealed the following. Resident # 14's speech was clear, she had herself understood, understands others, and her cognition was intact. Resident #14 had minimum depression, had no indicators of psychosis, had no behaviors, and did not reject care. Resident #14 required extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.