Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Chillicothe Post Acute during CMS and state inspections, most recent first.
Bathroom floors for multiple residents were observed to be torn, cracked, warped, and/or peeling away from the walls. A resident stated the floor needed replacement and staff were aware, and a Maintenance Assistant confirmed that some bathroom floors were in disrepair and quotes had been obtained for replacement.
Food was not consistently served at an appetizing temperature or acceptable palatability. Residents reported meals were often cold or not good, and one resident could not eat French toast because it was too hard to cut or chew. Test tray sampling also found milk and juice at low temperatures, and the DM verified the findings.
Improper Food Storage in Kitchen: During a kitchen tour, opened packages of hotdogs and pepperonis, a half-full container of sliced cheese, and an opened bag of chicken strips in the freezer were found with no dates. The DM confirmed the missing dates, and policy required refrigerated and frozen foods to be covered, labeled, and dated with a use-by date.
Failure to Trend In-House C-Diff Infections: The facility did not review in-house acquired C-Diff cases for patterns, clusters, or causative factors. Several residents were documented with facility-acquired C-Diff, but monthly infection tracking forms showed zero GI infections and no documented trending or further monitoring for the C-Diff cases. An LPN/Infection Control Nurse confirmed the lack of review.
A resident’s psychotropic medications were not ordered for appropriate diagnoses. The resident had bipolar disorder, anxiety, and insomnia, was cognitively intact with no behaviors, and had orders for citalopram and duloxetine for depression even though the DON stated the resident did not have a depression diagnosis and was receiving divalproex and citalopram for bipolar disorder.
Failure to update the care plan for elopement risk. A resident with moderate cognitive impairment, hemiplegia, aphasia, depression, and HTN was found outside in the parking lot trying to go home, later made repeated attempts to leave the building, and required a Wanderguard on the wheelchair for poor safety awareness. The care plan had no goals or interventions for unsafe wandering, elopement attempts, or the Wanderguard.
A resident with T2DM and multiple diabetes-related diagnoses did not have blood sugars monitored according to documented orders and facility protocol. Progress notes directed continued BG monitoring, but the chart lacked a current BG monitoring order, and an associate confirmed the facility did not have a BG monitoring protocol. The resident was receiving several diabetes medications, including insulin, oral agents, and PRN glucagon.
A resident with a sacral pressure ulcer, cellulitis, and aphasia had wound care orders that were not implemented or documented timely. The record showed no TAR entries or treatment documentation for several days after admission, and an LPN later entered an order that had been created by nursing without prior physician discussion. Staff interviews confirmed the wound care order was not in place until later, while the physician stated wound care orders were to be assessed by nursing and discussed with the physician or NP before being provided.
Failure to prevent resident elopement: A resident with hemiplegia, aphasia, depression, and moderate cognitive impairment was found in the parking lot trying to go home and later made multiple trips outside the building, resisting return inside. Although a Wanderguard order existed for poor safety awareness, staff documentation and risk assessments did not reflect the elopement history, and the care plan lacked related goals or interventions.
Tube feedings were not administered at the physician-ordered rates for two residents with PEG tubes. One resident with dysphagia, diabetes, and mildly impaired cognition was receiving Diabetisource AC at a lower rate than ordered and with a larger water flush than ordered, while another resident with a GT, aphasia, and a stage 3 sacral pressure ulcer was receiving Osmolite 0.5 calorie at a lower rate than ordered. An LPN confirmed the pump settings were incorrect for both residents.
A resident with acute and chronic respiratory failure with hypoxia and COPD was observed with an oxygen concentrator running beside the bed while the oxygen tubing was being changed. Review of the chart showed no physician order for oxygen therapy, and an RN confirmed the resident had been on oxygen since admission despite no order being in place. Facility policy required verification of a physician order before oxygen administration.
A resident with cellulitis, anemia, and atrial fibrillation received doxycycline longer than the hospital discharge order directed because the facility order had no stop date. The MAR showed the antibiotic was given for 22 days beyond the prescribed 9-day course, and the resident later had repeated loose stools/diarrhea and tested positive for C-Diff; an LPN/Infection Control Nurse confirmed the extended administration.
Medications were left unattended at a resident’s bedside. Surveyors observed a cup with multiple meds on the bedside table, and the cognitively intact resident confirmed her nurse usually leaves her pills for her if she is too tired to take them. The resident had diagnoses including CHF, DM2, and HTN, and the facility policy stated the nurse or medication aide should remain with the resident until all oral meds have been taken.
A resident was served lunch with gravy even though the meal ticket listed gravy as a dislike. The resident stated the facility was not honoring the likes and dislikes provided, and an LPN confirmed the meal included gravy. The facility also identified two other residents as not receiving food from the kitchen.
Inaccurate elopement and wandering documentation: A resident with hemiplegia, aphasia, depression, HTN, and moderate cognitive impairment was found in the parking lot trying to go home, and staff later documented multiple trips outside the building with resistance to returning inside. Although a Wanderguard order was entered for poor safety awareness, the elopement/wandering risk assessments repeatedly stated the resident had no unsafe wandering or elopement history and that a wander alarm was not indicated. During later observations, the Wanderguard was not on the resident's wheelchair or person, and the DON confirmed the assessments were inaccurate.
A resident with multiple medical conditions experienced an unwitnessed fall resulting in a head injury and hematoma. The LPN notified the family and unit manager promptly, but only sent a fax to the physician without direct verbal communication. The physician was unaware of the incident, despite facility policy requiring immediate phone notification for injuries involving head trauma.
The facility failed to properly thaw raw pork loins, which were found submerged in standing water at 62°F, contrary to policy requiring thawing under cold running water. This improper practice had the potential to affect all residents except two who were NPO.
The facility failed to maintain a safe and clean environment, with bathroom flooring in disrepair and room doors with gouges, affecting several residents. Additionally, a resident's request for linen change due to dried blood was not addressed promptly, violating the facility's policy. These deficiencies were confirmed through observations and interviews with residents and the Maintenance Director.
The facility failed to maintain resident dignity during dining, affecting two residents who consistently received their meals later than their roommates. Observations and interviews revealed that residents requiring assistance were prioritized, causing delays for others, leading to hunger and a lack of dignity.
A facility failed to invite a resident to care conferences, despite the resident being cognitively intact and willing to attend. The resident, with multiple diagnoses including diabetes and schizoaffective disorder, was unaware of any care conferences. Interviews with the DON and Social Services confirmed the absence of documentation regarding the resident's invitation or attendance, contrary to the facility's policy requiring such invitations and documentation.
A resident with chronic respiratory failure and dementia was transferred to the hospital without the necessary documentation, including the SNF/NF to Hospital Transfer Form, medication list, and bed hold notice. These documents were completed and sent only after the hospital requested them, as confirmed by the DON.
The facility failed to accurately code the MDS assessment for a resident, who was documented as discharged to a hospital but was actually transferred to hospice. This error was confirmed by an RN during an interview.
A resident in a long-term care facility developed a skin impairment after bumping their elbow during a shower. Despite the incident being reported to a nurse and a bandage being applied, there was no documentation or monitoring of the skin impairment in the resident's medical record. Interviews with staff revealed a lack of awareness and documentation regarding the incident.
A facility failed to assess and address PTSD in a resident, who had multiple chronic conditions, including PTSD. Despite being cognitively intact, the resident's care plan lacked details on PTSD causes, triggers, or interventions to prevent re-traumatization. The DON confirmed no assessment or care plan was in place for the resident's PTSD.
A facility failed to timely act on pharmacy recommendations for a resident's Keppra level monitoring. Despite a CNP accepting the recommendation for biannual lab draws, the first test was delayed by two months, affecting the resident's medication management.
A facility exceeded the acceptable medication error rate of 5%, reaching 6.67%, due to a nurse improperly crushing extended-release medications for two residents. One resident with severe cognitive impairment received crushed metoprolol succinate, and another resident with multiple health conditions received crushed Myrbetriq, both against physician orders. The errors were confirmed by the RN and verified by the DON.
A resident with a history of multiple health issues was identified as being at risk for dental problems. Despite a dentist's recommendation for tooth extraction due to discomfort from a probable broken tooth, the facility delayed sending a referral for extraction for several months. This resulted in the resident experiencing ongoing discomfort. Interviews confirmed the lack of timely follow-up on the necessary dental services.
The facility failed to ensure timely pneumococcal vaccinations and education for residents. A resident experienced a delay in receiving the vaccine after consent, another resident's family declined the vaccine without documented education on its risks and benefits, and a third resident was not offered additional doses as per CDC guidelines. Staff confirmed these deficiencies.
Bathroom Floors in Disrepair
Penalty
Summary
The facility failed to ensure that resident bathroom floors were in good repair, with observation showing the bathroom floors for Residents #10, #11, #20, #23, #31, #32, #35, #37, #52, #57, #61, #65, #66, #68, #76, #79, #87, #89, and #93 were torn, cracked, warped, and/or peeling away from the walls. The issue was identified during facility observation, and Resident #52 stated that the bathroom floor needed replacement and that staff were aware. A Maintenance Assistant also acknowledged that some bathroom floors in resident rooms were in disrepair and said the facility had obtained quotes because they needed to be replaced.
Food Served at Improper Temperature and Poor Palatability
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and served at a safe and appetizing temperature. During interviews, Resident #31 stated meals were hardly ever hot, and Resident #61 stated the food was not good and came out cold. Resident #73 reported that meals were alright but that they often received items they did not like or could not eat, such as corn and bread, and said dietary was aware of the preferences and had been reminded. During meal tray observation, Resident #69 complained that the French toast could not be cut or chewed and requested a substitute. Test tray sampling showed milk at 50.2 degrees and juice at 48 degrees, with temperatures verified by the Dietary Manager. Further investigation found the French toast was hard and could not be cut with a fork and butter knife.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to properly store food in the kitchen. During the initial tour, opened packages of hotdogs and pepperonis, a container half full of sliced cheese, and an opened bag of chicken strips in the freezer were observed with no dates. The Dietary Manager confirmed that the opened packages of hotdogs, pepperonis, sliced cheese, and chicken strips had no dates. Review of the Food Receiving and Storage Policy showed that foods stored in the refrigerator or freezer are to be covered, labeled, and dated with a use-by date, and that refrigerated foods are to be labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.
Failure to Trend In-House C-Diff Infections
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program by not ensuring residents with in-house acquired C-Diff infections were reviewed for patterns and trends to decrease the spread of infection. Record review and facility infection surveillance logs identified seven residents—#36, #42, #52, #71, #103, #104, and #228—who were documented by the facility as having acquired C-Diff in the facility since 11/01/2025. The facility census was 80. Review of the facility line listings showed in-house acquired C-Diff infections documented for Resident #42 on 11/19, Resident #103 on 11/20/25, Resident #52 on 11/21/25, Resident #104 on 11/26/25, Resident #36 on 12/05/25, Resident #42 again on 02/03/26, Resident #71 on 02/06/26, and Resident #22 on 02/15/26. However, the Healthcare Acquired Infection Rate - Tracking and Trending and Variance Analysis - Monthly Analysis of Trends forms for 11/2025, 12/2025, and 01/2026 showed the facility rate of gastrointestinal infections as zero, and no review of commonalities or clusters, causative factors, or plans for further monitoring or interventions for C-Diff infections was documented. An interview with the LPN/Infection Control Nurse confirmed there were no gastrointestinal infections documented on those monthly forms and no review of commonalities, clusters, causative factors, or plans for further monitoring or interventions for C-Diff infections.
Psychotropic Medications Ordered for Inappropriate Diagnosis
Penalty
Summary
The facility failed to ensure psychotropic medications were ordered for appropriate diagnoses for one resident. Resident #7 was admitted with diagnoses including radiculopathy, peripheral vascular disease, COPD, atherosclerosis of coronary artery bypass graft, and bipolar disorder with current episode hypomanic. The most recent psychiatric services documentation listed bipolar disorder, anxiety, and insomnia. The most recent MDS showed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Medication orders included citalopram 10 mg daily for depression and duloxetine 60 mg daily for depression. During interview, the DON stated that Resident #7 did not have a diagnosis of depression but was being ordered divalproex and citalopram for the mood disorder bipolar disorder.
Failure to Update Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop and update a care plan to address elopement risk for one resident reviewed for care plan accuracy. Resident #61 was admitted with diagnoses including hemiplegia and hemiparesis affecting the right side, aphasia following cerebral infarction, depression, and hypertension, and had a BIMS score of 10 out of 15 indicating moderate cognitive impairment. The annual MDS showed the resident was independently mobile with a manual wheelchair and required maximal assistance with toileting, showering, dressing, and positioning. Although the resident had no documented wandering, exit-seeking, or disruptive behaviors, a Wanderguard was in place. Nursing progress notes showed that the resident was found in the facility parking lot by an employee leaving at the end of a shift and stated he was trying to go home. He was assisted back inside, and a Wanderguard was applied to his wheelchair due to poor safety awareness. The resident later made multiple successful trips outside the building and was resistant to returning inside, requiring multiple staff members to encourage him back. Review of the care plan showed no goals or interventions addressing poor safety awareness, the Wanderguard, or the resident’s unsafe wandering or elopement attempts. The DON confirmed the post-incident elopement assessments were inaccurate and that the care plan should have been updated after the elopement and Wanderguard application.
Failure to Monitor Blood Glucose for Resident With Diabetes
Penalty
Summary
The facility failed to monitor a resident’s blood sugars according to orders, resident preferences, and goals. Resident #99 was admitted with diagnoses including urinary tract infection, Parkinsonism, and T2DM with hyperglycemia, T2DM with other specified complications, and T2DM with diabetic neuropathy. The record showed a discharge summary order for TRUEplus Lancets 33G, and progress notes from the nurse practitioner and medical director stated to continue blood glucose monitoring per facility protocol, but the resident’s orders did not include a current blood glucose monitoring order. Resident #99 was receiving multiple diabetes medications, including Glimepiride, Glucagon emergency injection as needed for low blood sugar, Insulin Glargine 45 units daily, Metformin ER 1000 mg twice daily, and Ozempic 2 mg weekly. The resident stated his blood sugar had not been checked as of the interview date, though it had been checked the day before by an associate. An associate confirmed the facility did not have a blood glucose monitoring protocol and stated orders had been obtained for accuchecks without coverage with meals and HGB A1C every six months.
Delayed and undocumented wound care for a resident with a sacral pressure ulcer
Penalty
Summary
The facility failed to ensure wound care orders for a resident with a sacrococcygeal pressure ulcer were implemented timely and appropriately. Resident #93 was admitted with diagnoses including a stage three pressure ulcer of the sacral region, cellulitis, and aphasia following cerebral infarction. The care plan identified impaired skin integrity present on admission with a stage four pressure ulcer to the sacrum and included interventions to administer treatments as ordered. A hospital WOC/ET consult note dated 02/20/26 directed Vashe-moistened gauze packing twice daily or once per shift, with an ABD or Sorbex pad and Medipore adhesive, and discharge instructions stated the resident could continue that care at discharge. Review of the record showed no treatment orders documented as implemented from 02/24/26 through 02/28/26, and the TAR also showed no wound care completed during that period. Although an order created by an LPN on 03/04/26 was documented as having been ordered on 02/25/26 and later added to the TAR, there was no documentation of wound care being completed on 02/26/26, 02/27/26, or 02/28/26. An LPN confirmed there had not been a physician order in place until 03/01/26, while another LPN stated she had obtained treatment orders from the on-call LPN and completed the treatment on 02/27/26 and 02/28/26. The on-call LPN confirmed she had given wound care orders, and the physician confirmed wound care treatment orders were to be assessed by nursing staff and discussed with the physician or NP before being provided.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure one resident was free from elopements and adequately supervised. The resident had diagnoses including hemiplegia and hemiparesis affecting the right side, aphasia following cerebral infarction, depression, and high blood pressure, and had a BIMS score of 10 out of 15, indicating moderate cognitive impairment. Although the resident was independently mobile with a manual wheelchair and had a Wanderguard in place, nursing progress notes documented that he was found in the parking lot by an employee leaving work after he was trying to go home. Staff assisted him back inside and applied a Wanderguard to his wheelchair. The record also showed that the resident made multiple successful trips outside the building and was resistant to returning inside, with staff later noting he continued to leave the facility with other staff members as they exited and required multiple people to encourage him to return. Despite this event, the Elopement and Wandering Risk Observation Assessments completed after the incident and on subsequent quarterly reviews stated he was alert and oriented, had never expressed a desire to leave, and had never exhibited unsafe wandering or elopement attempts, with the conclusion that a wander alarm was not indicated. The resident’s care plan contained no goals or interventions related to poor safety awareness, a Wanderguard, or a history of unsafe wandering or elopement attempts.
Tube feedings not administered at ordered rates
Penalty
Summary
The facility failed to ensure tube feedings were administered at the rate ordered by the physician for two residents reviewed for enteral feeding. Resident #87 had diagnoses including paroxysmal atrial fibrillation, type two diabetes mellitus, and dysphagia, and the admission MDS indicated mildly impaired cognition. The care plan identified the resident as at risk for malnutrition due to a gastrostomy tube and directed staff to administer enteral nutrition as ordered. The physician ordered Diabetisource AC via PEG tube at 85 ml per hour with a 75 ml water flush every four hours continuously, but observations showed the feeding running at 75 ml per hour with a 150 ml flush every four hours on two occasions. Resident #92 had diagnoses including a stage three sacral pressure ulcer, aphasia following cerebral infarction, and gastrostomy status. The care plan identified the resident as having a GT and being at risk for enteral nutrition complications, with interventions to provide tube care and check tube placement as ordered. The physician ordered Osmolite 0.5 calorie via PEG tube at 80 ml per hour continuously with a 100 ml free water flush every four hours, but observations showed the feeding running at 60 ml per hour with a 100 ml flush every four hours on two occasions. In both cases, the LPN confirmed the pumps were not set at the ordered rates and then adjusted them to the correct settings.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that orders were in place for oxygen administration for Resident #6. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, type II diabetes mellitus with diabetic neuropathy, and hepatic encephalopathy. The most recent MDS showed the resident was mildly cognitively impaired with a BIMS of 08 out of 15, had no behaviors, did not reject care, and did not wander. On 03/02/2026, an oxygen concentrator was observed running next to the resident’s bed, and the resident’s oxygen tubing was being changed. Review of the resident’s physician orders showed no order for oxygen therapy. RN #310 stated on 03/04/2026 that the resident had been on oxygen therapy since admission and confirmed that no oxygen order existed. Facility policy titled Oxygen Administration dated October 2010 stated that the first step is to verify that there is a physician’s order for the procedure.
Medication Continued Beyond Prescribed Duration
Penalty
Summary
The facility failed to ensure that medications were not administered longer than prescribed by the physician. Resident #103 was admitted with diagnoses including cellulitis of the right lower limb, anemia, and atrial fibrillation, and the hospital discharge orders dated 10/30/25 directed the resident to receive doxycycline 100 mg twice daily for 9 days. The facility physician order for doxycycline, also dated 10/30/25, did not include a stop date, and the Medication Administration Record documented that doxycycline was administered from 10/30/25 through 11/30/25, which was 22 days longer than ordered by the hospital. The resident had multiple documented episodes of loose stool/diarrhea beginning on 11/09/25 and continuing through 11/20/25, with fluids encouraged and stool softener held on some occasions. Laboratory results dated 11/20/25 showed the resident tested positive for C-Diff infection. A nurse practitioner note on 11/20/25 stated the resident had tested positive for C-Diff colitis and was still receiving doxycycline since discharge from the hospital; the note also documented significant nausea and that contact precautions were being initiated. An LPN/Infection Control Nurse confirmed that the resident continued receiving doxycycline beyond the hospital discharge order and that the documented loose stools/diarrhea occurred before the C-Diff diagnosis.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure that medications were not left unattended at a resident’s bedside. During an observation on 03/02/26 at 10:27 A.M., surveyors found a small cup containing multiple medications on Resident #31’s bedside table. Resident #31 confirmed that her medications had been left on her bedside and stated that her nurse will usually leave her pills for her in the morning if she is too tired to take them. Resident #31’s record showed an admission date of 10/07/25 and diagnoses including congestive heart failure, type II diabetes, and hypertension. Her MDS assessment completed on 10/14/25 indicated that she was cognitively intact. The record review also showed physician’s orders for medications administered in the 9:00 A.M. medication timeframe, including allopurinol 400 mg total daily, CoQ-10 200 mg daily, metoprolol succinate ER 50 mg daily, senna-docusate sodium 8.6-50 mg daily, sertraline HCl 100 mg daily, Eliquis 5 mg daily, and magnesium oxide 400 mg two tablets twice daily. The facility policy, Administering Oral Medications, revised 10/2010, stated that the nurse or medication aide providing medications should remain with the resident until all medications have been taken.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor a resident’s meal preferences by serving lunch that included beef tips and mashed potatoes with gravy even though the resident’s meal ticket listed dislikes that included broccoli-cauliflower, asparagus, pork, and gravy. During observation, the resident received the meal with gravy, and the resident later stated that the facility was not honoring the likes and dislikes provided. A staff member confirmed that the beef tips and mashed potatoes were covered in gravy and that gravy was listed as a dislike on the meal ticket. The facility identified two other residents as not receiving food from the kitchen.
Inaccurate elopement and wandering documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident with hemiplegia and hemiparesis affecting the right, non-dominant side, aphasia following cerebral infarction, depression, and high blood pressure. The resident had a BIMS score of 10 out of 15 on admission, indicating moderate cognitive impairment. After an incident in which the resident was found in the facility parking lot trying to go home, nursing staff assisted him back inside and applied a Wanderguard to his wheelchair. Nursing notes also documented that he made multiple successful trips outside of the building and was resistant to returning inside, but no further elopement attempts or unsafe wandering were documented in the medical record. The record also showed a physician order for a Wanderguard on the wheelchair due to poor safety awareness, but the Elopement and Wandering Risk Observation Assessments completed on admission and quarterly thereafter stated the resident was alert and oriented, had never expressed a desire to leave the facility, and had never exhibited unsafe wandering or elopement attempts, with each assessment concluding that a wander alarm was not indicated. During observations in March 2026, the Wanderguard was not on the resident's wheelchair or person, and an RN confirmed it was missing and attempted to apply a new bracelet, but the resident refused. The DON confirmed the post-incident elopement and wandering assessments were inaccurate and that the resident required a Wanderguard alarm.
Failure to Immediately Notify Physician After Resident Fall with Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure immediate physician notification following a resident's change in condition after an unwitnessed fall. The resident, who had a history of coronary artery disease, hydronephrosis, renal insufficiency, anxiety, depression, atrial fibrillation, and cardiomyopathy, was found on the floor next to her bed after reportedly rolling out. She sustained an open hematoma to the right lower leg, a knot on the back of her head, and a small red area to the right eyebrow. The resident was alert, complained of a headache, and was given Tylenol, which relieved her pain. Neurological checks were initiated and were negative, and the resident was moved to the nursing station for monitoring. The staff notified the family by telephone and the unit manager by text message. However, the attending physician was notified only via fax, and there was no direct verbal communication. The physician later stated he was not contacted about the fall and was unaware of the fax, emphasizing that the usual protocol required a phone call for injuries, especially those involving head trauma. The LPN involved acknowledged that after receiving no response to the fax, he should have called the physician directly but did not do so. Facility policy required prompt notification of the resident, physician, and representative in the event of a change in condition. The failure to provide immediate verbal notification to the physician, particularly in the context of an injury with head trauma, constituted a deviation from established protocols and resulted in the cited deficiency.
Improper Thawing of Raw Pork Loins
Penalty
Summary
The facility failed to ensure food was prepared in a manner to prevent food-borne illness, potentially affecting all residents except two who were NPO. During an observation, two large, uncooked pork loins were found submerged in standing water in a sink, with the water temperature measured at 62 degrees Fahrenheit. The Dietary Manager confirmed that the pork loins were improperly thawed in standing water, contrary to the facility's policy, which requires raw meats to be thawed under cold running water to prevent bacterial growth. The facility's policy also specifies that cold water thawing is not suitable for large cuts of meat that cannot thaw within four hours without exceeding 41 degrees Fahrenheit.
Facility Fails to Maintain Safe Environment and Timely Linen Changes
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by the poor condition of bathroom flooring and room doors. Observations revealed that the linoleum in several residents' bathrooms was taped down with dirty and tattered duct tape, with gaps between the linoleum and walls filled with dirt and debris. In some cases, the linoleum was loose and formed wave-like patterns, making it difficult and unsafe for residents, particularly those using wheelchairs, to navigate. Additionally, the bathroom and room doors had gouges, posing a risk of injury to residents. Interviews with residents and the Maintenance Director confirmed the long-standing disrepair of the flooring and doors, with the facility awaiting corporate approval for repairs. The facility also failed to change soiled linens in a timely manner, as observed in the case of a resident with dried blood spots on their bed sheets. Despite the resident's request for a change due to a skin tear, the linens remained unchanged for at least a day. The facility's policy stated that linens should be changed on shower days and as needed, but this was not adhered to in this instance. The deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's policies and resident care standards.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain resident dignity during dining experiences, affecting two residents. Observations revealed that a State Tested Nursing Assistant (STNA) fed Resident #41 while standing beside the bed, while Resident #242, the roommate, had not yet received a meal tray and expressed hunger. This pattern was repeated on another occasion, with Resident #242 consistently receiving meals significantly later than Resident #41, despite expressing a preference to receive meals simultaneously. Interviews confirmed that residents requiring assistance were prioritized for meal delivery, resulting in delays for other residents. Similarly, Resident #36 was observed without a meal tray while her roommate, Resident #31, was being fed by staff. Resident #36 reported always receiving her meal after her roommate, having to watch her eat first. The Dietary Manager confirmed that meal trays for residents needing assistance were sent out first, leading to delays for other residents. This practice resulted in residents experiencing hunger and a lack of dignity during meal times.
Failure to Invite Resident to Care Conferences
Penalty
Summary
The facility failed to ensure that residents were invited to participate in their care conferences, specifically affecting one resident. The medical record review for this resident, who was admitted with diagnoses including diabetes, schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, cerebral ischemic attack, restlessness, agitation, and impulsive behavior, showed no evidence of being invited to or attending care conferences. Despite being cognitively intact, the resident was unaware of any care conferences and stated she would have attended if invited. Interviews with the Director of Nursing and Social Services confirmed the lack of documentation regarding the resident's invitation or attendance at care conferences. The facility's policy required that residents be invited to quarterly interdisciplinary care conferences, with documentation maintained in the electronic medical record. However, there was no evidence that this policy was followed for the resident in question.
Failure to Provide Timely Transfer Documentation
Penalty
Summary
The facility failed to ensure that appropriate records and documentation were completed and sent with a resident upon transfer to the hospital. This deficiency affected a resident who was admitted with chronic respiratory failure, pulmonary disease, and dementia, and was assessed to have mildly impaired cognition. The resident experienced a change in condition and was transferred to the hospital. However, the SNF/NF to Hospital Transfer Form was not completed until the day after the transfer. Additionally, the medication list and bed hold notice were not sent at the time of transfer. The Director of Nursing confirmed that these documents were only faxed to the hospital after the hospital requested them.
Inaccurate MDS Coding for Resident Transfer
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for one of the residents reviewed. Specifically, the MDS assessment for Resident #82, who had a range of diagnoses including congestive heart failure and anxiety disorder, was incorrectly coded. The resident was documented as having been discharged to a short-term general hospital, whereas a progress note indicated that the resident was actually transferred to an inpatient hospice facility. This discrepancy was confirmed during an interview with Registered Nurse (RN) #66, who verified that the MDS was coded incorrectly.
Failure to Document and Monitor Skin Impairment
Penalty
Summary
The facility failed to ensure a new skin impairment on Resident #20 was assessed and monitored to promote healing. Resident #20, who was cognitively intact, had a bandage on his left elbow after bumping it during a shower, resulting in a small scrape. Despite the resident's report of the incident and the application of a bandage by a nurse, there was no documentation in the medical record regarding an assessment or monitoring of the skin impairment. Interviews with various staff members, including the Director of Nursing, Licensed Practical Nurse, Assistant Director of Nursing, and Unit Manager, revealed that none were aware of the skin impairment. A State tested Nursing Aide confirmed assisting the resident during the shower when the incident occurred and reported it to a Registered Nurse, who provided a bandage. However, the facility had no documentation related to the assessment, monitoring, or treatment of the skin tear.
Failure to Assess and Address PTSD in Resident
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the source of the PTSD and minimize triggers and/or re-traumatization. This deficiency affected one resident who was identified by the facility as having a diagnosis of PTSD. The resident had multiple diagnoses, including PTSD, chronic respiratory failure, diabetes mellitus type II, and several other chronic conditions. Despite being cognitively intact and having an active diagnosis of PTSD, the resident's care plan did not address the PTSD, its causes, potential triggers, or interventions to reduce the risk of re-traumatization. The medical record review revealed no evidence of an assessment to identify the cause of the resident's PTSD or potential triggers. An interview with the Director of Nursing confirmed that no such assessment had been completed, and no care plan was implemented to address the resident's PTSD to minimize the risk of re-traumatization.
Delayed Response to Pharmacy Recommendations for Medication Monitoring
Penalty
Summary
The facility failed to act promptly on pharmacy recommendations for a resident's medication monitoring. A resident, who was admitted with multiple diagnoses including epilepsy, was prescribed Keppra, an anti-seizure medication. The pharmacy recommended that Keppra levels be drawn every six months, a recommendation accepted by the Certified Nurse Practitioner (CNP) and ordered accordingly. However, the first laboratory draw for the Keppra level was not conducted until approximately two months after the recommendation and order were made. The delay in drawing the Keppra level was confirmed during an interview with the Director of Nursing (DON), who verified that the laboratory value was not obtained until two months after the pharmacy's recommendation. This oversight affected the resident's medication management, as no previous laboratory draws for Keppra levels had been completed prior to the delayed test.
Medication Error Rate Exceeds 5% Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.67%. This deficiency was identified during a survey where it was observed that a Registered Nurse (RN) crushed extended-release medications for two residents, which should not have been crushed. Resident #27, who was severely cognitively impaired and had multiple diagnoses including heart failure and vascular dementia, was administered crushed metoprolol succinate extended-release tablets, contrary to the physician's order. The RN confirmed the error during an interview, acknowledging that the medication should not have been crushed. Similarly, Resident #46, who was cognitively intact and had conditions such as cerebrovascular disease and multiple sclerosis, was given crushed Myrbetriq extended-release tablets. This was also against the physician's order. The RN admitted to crushing the medication, and the Director of Nursing verified with the pharmacy that the medication should not be crushed. These actions led to the facility exceeding the acceptable medication error rate, affecting the quality of care provided to the residents.
Failure to Follow-Up on Dental Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up on dental recommendations for a resident, leading to a deficiency in providing necessary dental services. Resident #23, who was cognitively intact and had a history of diabetes, schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, cerebral ischemic attack, restlessness, agitation, and impulsive behavior, was identified as being at risk for oral and dental problems. Despite being seen by a dentist on 09/27/23 for discomfort and a recommendation for tooth extraction due to a probable broken tooth, the facility did not send a referral for the extraction until 07/12/24. This delay resulted in the resident experiencing discomfort from broken teeth without timely intervention. Interviews with the resident and the Director of Nursing confirmed the lack of follow-up on the dental services needed from the time of the initial recommendation until the referral was finally made.
Deficiency in Pneumococcal Vaccination Protocols
Penalty
Summary
The facility failed to ensure timely offering, provision, and education regarding pneumococcal vaccinations for residents, as per CDC guidelines. Resident #23, who had multiple diagnoses including diabetes and chronic obstructive pulmonary disease, consented to the pneumonia vaccine on 09/15/23, but the vaccine was not administered until 10/02/23, indicating a delay in vaccination. Resident #25, with conditions such as hemiplegia and epilepsy, had their pneumococcal vaccine declined by their family, but there was no evidence that the resident or their responsible party received education on the vaccine's risks and benefits. Additionally, Resident #58, who had a history of heart disease and hemiplegia, received the Prevnar 13 vaccine in 2015 but was not offered or provided any additional doses of pneumococcal vaccinations as recommended by the CDC. The CDC guidelines suggest a dose of PCV20 or PPSV23 at least one year after the previous dose of Prevnar 13, which was not followed. Interviews with the Infection Preventionist and Minimum Data Set Nurse confirmed these deficiencies, acknowledging the delay in vaccination for Resident #23 and the lack of education and follow-up for Residents #25 and #58.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 122 citations issued within 25 miles in the last 12 months — including the 2 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Hopewell Grove Rehabilitation And Healthcare | 1.9 mi | ★★★★★ | 10 | 1 |
| Westmoreland Place | 2.4 mi | ★★★★★ | 0 | 0 |
| National Church Residences Chillicothe | 2.9 mi | ★★★★★ | 11 | 0 |
| Vineyards At Concord, The | 13.4 mi | ★★★★★ | 33 | 0 |
| National Church Residences Bristol Village | 13.9 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Chillicothe Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.