National Church Residences Chillicothe

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.