Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arc At Chillicothe during CMS and state inspections, most recent first.
Delayed assessment and treatment of right heel pressure injury. A cognitively intact resident with multiple comorbidities returned from the hospital with an unstageable R heel pressure injury, but the facility did not document timely skin assessments, did not implement the hospital-ordered wound treatment for several days, and did not notify the wound physician until later. The care plan was not updated to reflect the unstageable wound, and observations showed the resident’s heels resting directly on the bed without offloading or the ordered heel boot in use.
Grievance forms were not readily available and grievance/complaint procedures were not posted in a prominent location. Several residents said they had never been shown how to file a grievance, where to find the forms, how to submit one anonymously, or who the grievance official was. During a tour, the Administrator could not locate the forms and stated she was not aware of the procedure being posted anywhere; the Social Service Director was identified as the grievance official, and staff said forms were kept behind the nurse's station desk in a binder.
A resident was transferred to the hospital multiple times, but the medical record did not show that written transfer notices were provided to the resident or family. The DON confirmed the facility did not have a formal transfer form and said staff only notified families by phone, with no documented written reason for the transfer.
Failure to Offer Bedtime Snacks: Residents reported they were not offered HS snacks and wanted them offered. A CNA stated staff do not go around offering bedtime snacks to all eligible residents, and the DON said snacks are kept at nurse stations for residents to request. The Dietary Manager stated snacks are actively distributed only on one hallway, while on another hallway they are available only upon request. Facility policy calls for bedtime snacks and/or fluids as appropriate.
Failure to Report Allegations of Abuse and Neglect: The facility did not report resident allegations of staff verbal/mental abuse and neglect to the abuse coordinator or state agency. One resident with self-care deficits and high abuse/neglect risk reported a CNA refused to help her get up and left her crying, while another resident reported an RN was disrespectful and aggressive during a medication interaction that escalated into yelling. Staff and leadership acknowledged the concerns were not properly reported or investigated.
Failure to Investigate Abuse Allegations and Protect Residents: A resident who needed staff help for transfers reported that a CNA refused to assist her and was mean to her, but the chart had no abuse investigation, statements, or progress notes, and the DON and administrator confirmed the employee was only moved off the resident’s hall. Another resident reported an RN was aggressive and verbally rude during a PRN med request, leaving her humiliated, yet staff acknowledged no investigation had been started and a CNA did not report the concern because she did not want to be involved.
A resident with diabetes who used oral medication and did not receive insulin had MDS assessments that incorrectly coded one insulin administration in the prior 7 days. The LPN/MDS coordinator confirmed the assessments were coded for insulin because of Trulicity, a GLP-1, even though it is not insulin.
Unclean, Untrimmed Fingernails: A resident with severe cognitive impairment and hospice services was observed in a wheelchair with fingernails that were long past the fingertips, jagged, and had brown debris underneath. A CNA confirmed the nails needed to be trimmed and cleaned, and the DON stated fingernails should be cleaned and trimmed with each shower or as needed. The facility's nail care policy required staff to observe nail condition during bathing and note cleanliness and length.
Failure to provide ROM programs for two residents with significant functional limitations. One resident with MS, paraplegia, and paralysis and another resident with stroke-related hemiplegia and hemiparesis both had restorative assessments showing they would benefit from ROM, yet both stated staff did not perform ROM exercises. The restorative nurse was unsure why passive ROM was not in place and said both residents could benefit from it due to contractures; a COTA also agreed both would benefit from a ROM program.
Failure to check gastric tube placement and residual before enteral feedings. An RN and an LPN administered meds, flushes, and enteral feedings to two residents with gastrostomy tubes without first verifying tube placement or checking gastric contents/residuals, despite physician orders and facility policy requiring those checks.
Failure to use required PPE during EBP high-contact care. An LPN administered enteral feeding to a resident with a gastrostomy tube without donning a gown, and two CNAs dressed and transferred another resident with a wound on EBP without wearing gowns. The RN/IP confirmed that gown and glove use was required for high-contact care, including transfers and device-related care.
The facility failed to prevent abuse when two residents engaged in a verbal and physical altercation in a dining room. One resident reported disliking another resident’s conversation, after which the other resident allegedly gave the middle finger, told the first resident to mind her own business, and struck her in the stomach with an open hand. Witnesses, including a visitor and HR staff, reported seeing both residents yelling, one resident attempting to hit the other, and both residents striking or swinging at each other in the chest area before staff intervened and separated them. The facility’s abuse policy affirms residents’ right to be free from abuse and defines abuse as the willful infliction of injury, yet this incident involved resident-to-resident physical and verbal abuse.
A resident fell and sustained a head injury after a CNA attempted to move her wheelchair over an air mattress cord left on the floor, rather than removing the hazard. The CNA lifted the back of the wheelchair, causing the resident to fall forward and strike her head on a mechanical lift, in violation of the facility's fall prevention policy.
A resident admitted with acute respiratory failure and pneumonia did not receive ordered lab tests. Despite a Nurse Practitioner's order for stat lab work, the tests were not completed, and no results were documented. The resident's daughter was informed of the oversight, and the facility's process for handling lab orders was not followed, as confirmed by the DON.
A resident with acute respiratory failure and moderate cognitive impairment experienced a delay in treatment due to the facility's failure to promptly report and review x-ray results indicating pneumonia. The x-ray was ordered but not acted upon until six days later, despite the resident's ongoing symptoms. The facility's process for handling diagnostic tests involved communication breakdowns, leading to the delay in initiating appropriate treatment.
The facility failed to ensure dietary staff fully covered their hair in the kitchen and improperly stored a chemical product in an unlocked cabinet in the dining room. The Dietary Manager and two Dietary Aides were observed with uncovered hair, violating the facility's hygiene policy. Additionally, a full container of All Purpose Cleaner was found in an unlocked cabinet, contrary to the chemical use procedures. These deficiencies potentially affected 89 of the 90 residents consuming food at the facility.
A facility failed to secure a controlled substance, Lorazepam, in a double-locked location for a resident. The medication was found in an unlocked cabinet in the South Hall Medication Room. The DON stated the medications were from the resident's home and should have been sent back with the family upon admission. The Lorazepam should have been counted by two nurses, documented, and placed in a double-locked controlled substance drawer or secured in a second locked location.
The facility failed to make the State Survey Results Binder readily accessible to residents, as it was located in a non-wheelchair accessible foyer requiring an electronic code for entry. Two residents were misinformed about the binder's location, and staff confirmed that residents needed assistance to access it, affecting all 90 residents.
A facility failed to follow a physician's wound care order for a resident with a stage 4 pressure ulcer. The resident's care plan included several diagnoses, and the physician's order specified using calcium alginate and an ABD pad. However, a hydrocolloid dressing was used instead, as confirmed by an LPN. The DON stated that all nurses are expected to follow the physician's orders.
A facility failed to timely obtain a urinalysis for a resident with acute kidney failure and diabetes, leading to a delay in diagnosing a urinary tract infection. A physician ordered the test, but the sample was collected and sent to the lab several days later, delaying results and treatment. The DON confirmed the test should have been completed within 24 hours, and the physician notified if there were collection issues.
Delayed assessment and treatment of right heel pressure injury
Penalty
Summary
The facility failed to ensure a resident with multiple medical diagnoses, including morbid obesity, heart failure, acute kidney failure, and difficulty walking, received accurate skin assessments and timely wound care after returning from the hospital with an unstageable pressure injury to the right heel. The resident was cognitively intact, dependent on staff for toileting, bathing, dressing, and transfers, and her admission care plan did not include interventions to prevent pressure ulcers. The record also showed a treatment order for Skin Prep to the right heel beginning before the hospital transfer, but there was no skin assessment documented for the right heel from the time the treatment was obtained until the resident went to the hospital. Hospital records documented that the resident had an unstageable pressure ulcer to the right heel present on admission to the hospital, with wound care orders to cleanse with normal saline and apply a moisture wicking dressing covered by a foam dressing every 48 hours. After the resident returned to the facility, the admission skin assessment documented no skin concerns or pressure ulcers, and the care plan was initiated with a pressure blister to the right heel but was not revised to reflect the unstageable pressure ulcer or include appropriate pressure relief and wound management interventions. The treatment administration record for the first five days after readmission did not show the ordered right heel treatment, and the medical record did not include documentation or skin assessment of the wound during that period. A wound note later documented that the wound physician was notified by the facility medical director and identified the right heel wound as an unstageable pressure ulcer with dead skin, measuring 2.9 cm by 2.6 cm with unmeasurable depth due to nonviable tissue and necrosis. The wound physician ordered a pressure-relieving boot and heel offloading, but observations later showed the resident lying in bed with both heels resting directly on the bed, without a low air loss mattress in place and without the heel boot in use. Staff stated the resident had a fluid-filled blister before hospitalization but could not find documentation of a blister, skin assessment, or measurements, and the wound physician stated he was not notified until several days after readmission.
Grievance Forms Not Readily Available and Procedures Not Posted
Penalty
Summary
The facility failed to provide readily available grievance forms and failed to post grievance and complaint procedures in a prominent location throughout the building. During interviews on 4/21/2026, residents R15, R27, R37, R84, and R87 stated they had never been shown how to fill out a grievance, where the grievance forms were located, how to fill one out anonymously, or who the grievance official was to receive the forms. During a tour with the Administrator, V1 was asked to show where grievance forms were located for residents and where the grievance procedure was posted in the facility. V1 could not locate the forms and thought they may be at each nurse's desk, but was unable to find them at that time. V1 stated she was not aware of the grievance procedure being posted anywhere and identified V10, the Social Service Director, as the grievance official. V25 stated grievance forms were located behind the nurse's station desk in a binder and that residents would have to ask for a form; V25 also stated there was nothing posted around the facility explaining how to file a grievance or who to turn the grievance paper into. The facility's grievance policy stated grievances may be filed orally, in writing, or anonymously, and that an appointed grievance official is responsible for overseeing the grievance process.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to ensure residents and/or resident families were provided with a written notice of transfer when residents were transferred to the hospital. During record review and interview, R13 stated she had been sent back and forth to the hospital multiple times for numerous reasons while in the facility. R13’s electronic medical record showed transfers out of the facility to the hospital on 1/4/26 and again on 2/28/26, but the record did not document that written notice of transfer was provided at the time of either transfer. The DON confirmed that R13 did not have any written notices of transfer explaining why she was being sent to the hospital and stated the facility did not have a formal transfer form for residents or families. The DON also stated the facility notified families by telephone but did not have a form documenting the reason for transfer provided to residents or family members, and that this practice had not been followed because staff were unaware it was required.
Failure to Offer Bedtime Snacks
Penalty
Summary
The facility failed to offer bedtime snacks to residents reviewed for bedtime snacks in a sample of 35. The electronic health records for R15, R27, R37, R84, and R87 did not contain documentation that R17, R18, R27, R30, R38, and R52 were offered or received bedtime snacks. During the resident council meeting, R15, R27, R37, R84, and R87 stated they were not offered bedtime snacks and would like them to be offered. On interview, a CNA stated she did not go around and offer snacks at bedtime to all residents who could have them, and that residents could ask for one if they wanted it. The DON stated dietary staff provide a drawer of snacks at each nurse’s station where a resident can ask for a snack. The Dietary Manager stated a dietary aide distributes ice cream to the Medicare hallway nightly at 6:15 PM and then leaves snacks at both nurses’ stations, but for the North/South hallway snacks and ice cream are not actively offered or distributed by dietary staff and are available only upon request. The facility’s Snacks and House Supplements Policy states house snacks provide additional calories and meet individualized nutritional and care plan needs, and the Bedtime Care Policy states to provide bedtime snack and/or fluids as appropriate.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of staff-to-resident mental abuse and neglect to the abuse coordinator and the state agency for three residents. The facility’s abuse policy required immediate reporting of any allegation or suspicion of abuse, neglect, retaliation, exploitation, mistreatment, or misappropriation of property, and required an investigation to be initiated upon learning of a report. The policy also defined verbal abuse, mental abuse, retaliation, and neglect, and stated that allegations of abuse were to be reported to the state agency immediately, but not more than two hours after the allegation, with other incidents reported within 24 hours. For one resident, who had a care plan documenting self-care deficits and a high risk for abuse/neglect related to depression, the resident stated that about three weeks earlier a CNA refused to help her get up, told her no, and left her crying and upset for weeks. The resident also stated she believed the CNA did not like her and that the CNA was no longer allowed to care for her. The Administrator later confirmed she had been informed of a complaint around the end of March 2026, that the resident had made a statement that the CNA may have caused harm to her roommate, and that no abuse investigation was initiated and nothing was reported to the state. For another resident, the resident reported that an RN was disrespectful and aggressive during a third-shift interaction involving a request for Meclizine, and that the exchange escalated into yelling, leaving the resident feeling humiliated and dismissed. The RN’s note documented a disagreement with the resident about the timing of the request and included a statement that the RN was busy with another resident. A CNA stated the resident had reported that third-shift staff were mean and verbally rude, but the concern was not reported because the CNA did not want to involve herself in the drama. The DON acknowledged awareness of concerns about the Meclizine order and stated she had not spoken directly with the resident before the order change, and the Administrator stated she had not been made aware of the verbal abuse allegations.
Failure to Investigate Abuse Allegations and Protect Residents
Penalty
Summary
The facility failed to ensure that abuse allegations were investigated and that residents were protected from alleged perpetrators of mental abuse and neglect for three residents reviewed. The report describes that one resident with a self-care deficit and dependence on staff for bed mobility and transfers reported that a CNA had been mean, refused to help her get up, and left her crying and upset for weeks. The resident stated she believed the CNA refused to help because the CNA did not like her, and she said the administrator later told her the employee would no longer care for her. However, the resident’s record did not contain an investigation, progress notes, or care plan updates related to the allegation, and the facility’s reported abuse allegations and investigations did not include the incident. Facility staff confirmed that there had been conflict involving the resident and a CNA, that the CNA was moved to another floor or hall, and that the resident no longer wanted that staff member in her room. The DON stated the facility did not prohibit the CNA from caring for the resident, only kept the CNA off the resident’s hall for preference and to avoid conflict. The DON also stated there was no documentation from the incident, no written staff statements, and no additional resident interviews beyond one roommate. The administrator confirmed she was informed of the complaint, acknowledged there was no documentation in the resident’s record, and stated she did not initiate an abuse investigation, suspend the employee during investigation, or keep a file with statements and interviews. A second resident reported verbal abuse by an RN during a third-shift interaction involving a PRN Meclizine request after a recent hospitalization changed the medication from scheduled to PRN. The resident stated the RN questioned her need for the medication in an aggressive manner, returned with printed material disputing her explanation, and the exchange escalated into yelling, leaving the resident feeling humiliated and dismissed. The DON acknowledged prior knowledge of concerns about the medication but had not spoken directly with the resident, and she identified the RN’s progress note documenting an argumentative interaction as inappropriate. A CNA stated the resident had complained that third-shift staff were mean and verbally rude, but the CNA did not report the concern because she did not want to be involved, and she did not question other residents or staff. The administrator confirmed there was no evidence that an investigation had been initiated when the allegation was reported.
Inaccurate MDS Coding for Insulin Use
Penalty
Summary
The facility failed to ensure that a resident’s MDS assessments were completed accurately to reflect insulin usage. The resident stated she has diabetes but controls it with oral medication and does not receive insulin injections. Her physician order sheet for the relevant period did not document any prescribed insulin medication. However, the resident’s MDS assessments dated 1/2/26, 1/22/26, and 3/16/26 each documented that she received one insulin administration in the last seven days. The LPN/MDS coordinator confirmed that the assessments were coded for insulin even though the resident does not receive insulin, and stated the coding was marked because of an order for Trulicity, which is a GLP-1 and not insulin.
Unclean, Untrimmed Fingernails
Penalty
Summary
The facility failed to ensure a resident's fingernails were kept clean and trimmed for one resident reviewed for ADLs. The resident was a female admitted with diagnoses including Senile Degeneration of Brain, Age-Related Osteoporosis, Frontotemporal Neurocognitive Disorder, Hypertension, Chronic Kidney Disease, Dementia, and Major Depressive Disorder. Her MDS dated 2/25/26 documented that she was severely cognitively impaired and receiving hospice services, and her care plan stated she required assistance from one staff member with personal hygiene. During observation on 4/20/26, the resident was sitting in the dining room in her wheelchair, and her fingernails were observed to be long past the fingertips, jagged, and with brown debris underneath. A CNA verified the nails were long, jagged, and dirty and stated they needed to be trimmed and cleaned. The DON stated resident fingernails should be cleaned and trimmed with every shower or as needed. The facility's Nail Care Policy dated 12/2025 directed staff to observe nail condition during bathing and note cleanliness, length, uneven edges, and hypertrophied nails.
Failure to Provide Range of Motion Programs for Two Residents
Penalty
Summary
The facility failed to implement a range of motion program for two residents with known functional limitations, R7 and R14. R7 was admitted with relapsing-remitting multiple sclerosis, paraplegia, and muscle wasting and atrophy. His physician orders included no weight bearing to the right lower extremity and an ankle brace to the right ankle. The restorative assessment documented that he required staff assistance for all ADLs, would benefit from a ROM program, and had functional limitations and paralysis in both upper and lower extremities. During observation, R7 was up in a wheelchair with a brace on the right leg and stated that staff do not perform ROM exercises for him. R14 was admitted with cerebral infarction and hemiplegia and hemiparesis affecting the right dominant side. Her physician orders included evaluation and treatment for a new brace to the right forearm and right leg due to weakness from stroke. The restorative assessment documented that she required staff assistance for all ADLs, would benefit from a ROM program, and had functional limitations and paralysis in the right upper and lower extremities. During observation, R14 was in bed with a splint to the right wrist and right leg and stated that staff do not perform ROM exercises for her. The restorative nurse stated she was unsure why R7 and R14 did not have passive ROM programs and stated both could benefit from passive ROM due to contractures. The COTA also stated that, in her opinion, both residents would benefit from a ROM program.
Failure to Check Gastric Tube Placement and Residual Before Enteral Feedings
Penalty
Summary
The facility failed to check gastric tube feeding residual prior to administering enteral feedings for two residents with gastrostomy tubes. R9 had diagnoses of dysphagia following cerebral infarction and gastrostomy status, and the physician orders and care plan directed staff to check tube placement before feeding and to check tube placement and gastric contents/residual volume per facility protocol. On 4/21/2026, an RN entered R9's room, connected a 60 cc syringe to the gastrostomy tube, flushed the tube with 30 cc of water, administered pre-mixed medications and 325 cc of prescribed formula, and followed with 50 cc of water without checking tube placement or gastric contents first. The RN later verified that tube placement had not been checked before the medications, flushes, and feeding were given. R34's physician orders directed staff to check residuals before beginning a feeding and before medication administration, and to hold feedings and recheck in one hour if residual was greater than 100 ml. On 4/20/26, an LPN washed her hands, applied gloves, opened the gastrostomy tube cap, flushed it with 30 ml of water, administered 240 ml of enteral feeding in 60 ml portions, and flushed the tube again with 30 ml of water after the feeding. The LPN did not check for tube placement before feeding R34, and later verified that she had not checked placement prior to administering the enteral feeding. The facility policy on gastrostomy tube feeding and care directed staff to aspirate to visually verify stomach contents before feeding.
Failure to Use Required PPE During EBP High-Contact Care
Penalty
Summary
The facility failed to don the required personal protective equipment during high-contact care for two residents who were on Enhanced Barrier Precautions (EBP). One resident had a current physician order sheet documenting EBP related to a gastrostomy tube. During enteral feeding administration, an LPN washed her hands and applied gloves, opened the gastrostomy tube cap, flushed it with 30 mL of water, and poured 60 mL at a time of ordered enteral feeding to total 240 mL, but did not apply PPE before providing the feeding. The LPN later confirmed that she did not put on a gown before administering the resident’s enteral feeding. The Infection Preventionist stated that the appropriate PPE is to be donned before any high-contact care. A second resident’s care plan, dated 8/6/25, documented an actual pressure impairment to the coccyx and EBP related to wounds, with instructions to gown and glove during high-contact resident care activities including dressing, bathing, changing briefs, assisting with toileting, or wound care. Two CNAs were observed getting the resident up, dressing him, and performing a mechanical lift transfer without wearing gowns. One CNA confirmed that the resident had a wound and was on EBP, and stated that gowns were not required for dressing and transfer. The RN/Infection Preventionist later confirmed that staff should have been wearing a gown and gloves during transfers for residents in EBP precautions.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect residents from abuse when two residents engaged in a physical and verbal altercation in the dining room. On 2/11/26 at approximately 2:40 p.m., the facility was notified of alleged resident-to-resident contact between R7 and R8, and an initial abuse investigation documented that the residents were separated immediately. The final abuse investigation dated 2/12/26 states that R7 reported she did not like a conversation R8 was having with another resident, that R8 gave her the middle finger and told her to mind her own business, then used an open hand to make physical contact with her stomach, after which R7 made physical contact with R8’s chest with her left hand. Facility interviews document that a visitor (V11) saw R7 trying to hit R8 while both were yelling, that R8 tried hitting or hit R7 and R7 continued trying to reach for R8, and that the HR staff member (V10) observed R7 hit R8 in the chest with her fist and then saw R8 start swinging back at R7. Two staff members overheard the argument in the dining room and separated the residents, and the Administrator later acknowledged there had been resident-to-resident abuse involving R7 and R8 that was reported to the state. R7 subsequently stated she had a verbal issue with R8 and that he hit her in the stomach after giving her the middle finger. The facility’s Abuse Prevention and Reporting policy affirms residents’ right to be free from abuse and defines abuse as the willful infliction of injury, but the incident demonstrates that residents were subjected to physical and verbal abuse by another resident.
Failure to Maintain Hazard-Free Environment Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident's environment was not kept free of hazards, resulting in a fall. The incident involved a certified nursing assistant (CNA) who was preparing a resident in her room. The CNA encountered cords from an air mattress that were lying on the floor in front of the resident's wheelchair. While attempting to move the wheelchair over the cord, the CNA lifted the back of the wheelchair, causing the resident to fall forward out of the chair and hit her head on a mechanical lift. The resident sustained a bleeding injury to the right side of her head, which required cleansing and monitoring. The facility's fall prevention policy requires that resident environments be kept free of clutter and hazards, and that appropriate interventions be implemented based on individual risk assessments. In this case, the CNA did not remove the cord from the resident's path before attempting to move the wheelchair, and lifted the wheelchair in a manner that led to the resident's fall. The Director of Nursing confirmed that the CNA should have moved the cord and not lifted the wheelchair, indicating a failure to follow established safety protocols.
Failure to Complete Ordered Lab Tests for Resident
Penalty
Summary
The facility failed to ensure that laboratory testing was completed as ordered for a resident who was admitted with a primary diagnosis of acute respiratory failure with hypoxia. The resident was supposed to have stat lab work done following a follow-up visit by a Nurse Practitioner, who also ordered the continuation of an antibiotic for pneumonia. However, the lab order, which was placed in the computer to be completed the following day, was not executed, and no lab results were documented in the resident's records. The resident's daughter reported that upon admission, the resident had been complaining of a cough and sore throat, which led to an x-ray and a pneumonia diagnosis. She was informed that labs were to be done, but later discovered from a nurse that the labs were never completed. The facility's process for handling lab orders involves filling out a paper form and placing it in an accordion file for the lab to collect. The Director of Nursing confirmed that the lab work was not done as it should have been. The facility's policy requires a licensed nurse to ensure that lab orders are communicated to the laboratory and that results are reported to the physician promptly.
Delayed Reporting of Diagnostic Test Results
Penalty
Summary
The facility failed to ensure timely reporting and review of diagnostic testing results for a resident with a primary diagnosis of acute respiratory failure with hypoxia. The resident, who had moderate cognitive impairment, was ordered a repeat chest x-ray by a Nurse Practitioner due to a history of bilateral pleural effusions. The order was noted by nursing staff two days later, and the x-ray results, which indicated right basilar opacity suggestive of pneumonia, were reported on the same day. However, the results were not acted upon until six days later when an antibiotic was ordered. The delay in treatment was highlighted by the resident's daughter, who reported that her father had been complaining of a cough and sore throat upon admission, but no immediate action was taken. The facility's process for handling x-ray orders involved placing the order in the computer, scheduling the exam, and faxing results to the provider. However, there was a breakdown in communication and follow-up, as the results were not promptly forwarded to the medical group for review. The Director of Nursing acknowledged that the x-ray order should have been processed and completed earlier, which would have allowed for timely initiation of treatment.
Non-compliance with Hair Coverage and Chemical Storage Policies
Penalty
Summary
The facility failed to ensure that dietary staff adhered to the established hygiene policy requiring complete hair coverage while in the kitchen. During an observation, the Dietary Manager and two Dietary Aides were found with hair not fully covered, contrary to the facility's policy. The Dietary Manager's bangs were exposed, and she acknowledged the oversight, stating that her hair had slipped out. Similarly, the Dietary Aides had uncovered hair on the sides and back of their heads, which they admitted was against the kitchen staff's requirements. This lack of compliance with the hair covering policy was observed during a time when the Dietary Manager was substituting as a cook. Additionally, the facility did not comply with its housekeeping chemical use procedures, which mandate that all chemicals be stored in a locked cabinet or remain in the user's line of sight. A full container of All Purpose Cleaner was found in an unlocked lower cabinet in the dining room, posing a potential risk to residents. The Dietary Manager was unaware of how the chemical ended up in the cabinet and confirmed that it should have been locked to prevent resident access. These deficiencies potentially affected 89 of the 90 residents who consume food at the facility.
Failure to Secure Controlled Substance in Double-Locked Location
Penalty
Summary
The facility failed to secure a controlled substance medication in a double-locked location for a resident reviewed for medication storage. During an observation, a plastic bag containing medications labeled with the resident's name, including a bottle of Lorazepam 0.5mg tablets, was found in an unlocked cabinet in the South Hall Medication Room. Lorazepam is a Schedule IV controlled substance prescribed for anxiety. The Director of Nursing (DON) stated that these medications were brought from the resident's home and should have been sent back with the family upon the resident's admission. The DON acknowledged that the Lorazepam should have been counted by two nurses, documented on the facility's Controlled Drug Record/Disposition Form, and placed in a double-locked controlled substance drawer or secured in a second locked location within the Medication Room.
Inaccessible Survey Results Binder
Penalty
Summary
The facility failed to ensure that the annual State Survey Results were readily and easily accessible to residents, which is a violation of the residents' rights as outlined in the facility's Resident Rights Policy. The policy guarantees residents the right to examine survey results, but the Survey Results Binder was located in a cabinet drawer in the front foyer, an area that was not wheelchair accessible and required an electronic code for entry. Residents did not have access to this code, effectively preventing them from accessing the survey results independently. During a Resident Council Meeting, two residents were informed by the Activities Director that the Survey Results Binder was located at the East Wing Nursing Station. However, when one of the residents requested to see the binder, it was not found at that location. The Activities Director later confirmed that the binder had been moved to the front foyer during a facility remodel in 2017. Staff interviews revealed that residents would need assistance to access the binder, as they could not reach the foyer on their own. This oversight potentially affected all 90 residents residing in the facility.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to apply the correct treatment to a wound for one resident, identified as R6, who was reviewed for wounds. R6's care plan, initiated on 5/6/2024, includes diagnoses such as a wedge compression fracture, Alzheimer's disease, difficulty in walking, musculoskeletal symptoms, and protein-calorie malnutrition. R6 was assessed to be at moderate risk for skin breakdown and had a facility-acquired stage 4 pressure ulcer on the left buttock. The physician's order dated 8/12/24 specified cleansing the wound, patting it dry, applying calcium alginate, and covering it with an ABD pad daily and as needed. However, on 8/20/24, a hydrocolloid dressing was observed on R6's wound, which was not in accordance with the physician's order. The LPN confirmed the treatment order and stated that other nurses sometimes used the hydrocolloid dressing when the ABD pad became soiled. The Director of Nursing stated that all nurses are expected to follow the physician's orders.
Delayed Urinalysis Collection and Testing
Penalty
Summary
The facility failed to obtain a urinalysis in a timely manner for a resident who was being reviewed for urinary tract infections. The resident had medical diagnoses including acute kidney failure, type 2 diabetes mellitus with hyperglycemia, difficulty in walking, and lack of coordination. A physician ordered a urinalysis on June 28, 2024, but the urine sample was not collected until July 2, 2024, and sent to the lab on July 3, 2024. The microbiology results detected Escherichia coli Extended Spectrum Beta-Lactamase (ESBL) in the urine. The Director of Nursing confirmed that the urinalysis should have been completed the same day or the next day after the order was given, and if there were difficulties in collecting the sample, the physician should have been notified. This delay in collecting and sending the urine sample resulted in a delay in obtaining the urinalysis results and subsequent treatment for the resident's urinary tract infection.
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Illustrative
What surveyors actually found near you
We read the 172 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chillicothe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lacon Rehab And Nursing | 9.7 mi | ★★★★★ | 7 | 1 |
| Lutheran Hillside Village | 10.1 mi | ★★★★★ | 1 | 0 |
| Arcadia Care Peoria Heights | 10.8 mi | — | 9 | 0 |
| Goldwater Care Peoria Heights | 10.8 mi | ★★★★★ | 25 | 3 |
| Snyder Village | 10.9 mi | ★★★★★ | 0 | 0 |
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