Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at National Church Residences Chillicothe during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple chronic conditions, and a history of several unwitnessed falls had specific fall-prevention interventions ordered, including a lowered wheelchair seat, wedge cushion, reacher/grabber tool, and non-skid strips by the bed. Surveyors observed that these interventions were not in place: the wheelchair back was not lowered, no wedge cushion was present, non-skid strips were absent, and the reacher/grabber was stored out of the resident’s reach. Staff interviews confirmed the resident was very confused and required assistance and reminders not to transfer independently, yet the facility did not ensure that the care-planned and post-fall interventions were implemented as required by its own falls management policy.
PASARR screenings were not completed or updated for two residents after psychotic diagnoses were identified or added. One resident’s PASARR only listed mood behaviors and panic or severe anxiety, even though the record and MDS also showed psychotic disorder; the SSL confirmed the psychotic disorder was not captured in PASARR section E. Another resident had dementia, Alzheimer’s disease, Parkinsonism, and psychotic disorder, and when a new diagnosis of psychotic disorder with delusions and hallucinations was added, the DON verified no new PASARR was completed.
A resident with multiple diagnoses, including Alzheimer’s disease, dementia, and severely impaired cognition, did not have a comprehensive care plan addressing those conditions. Review of the current care plan showed no interventions in place for the resident’s Alzheimer’s disease and dementia, and the DON verified the omission.
Delayed Treatment of UTI: A resident with multiple chronic conditions and occasional bladder incontinence developed dysuria and had a UA C&S ordered, but the lab results were received without antibiotics being started for a positive UTI. The resident’s daughter later reported the results had been reviewed in the EMR with no treatment initiated, and the DON verified there was a delay before Bactrim DS was ordered and the first dose was given.
Medication administration errors exceeded the allowed rate when an LPN failed to prime insulin injector pens for two residents and omitted an ordered ascorbic acid dose for another resident. One resident had type II DM, cirrhosis, CKD stage 3, and an insulin aspart order; another had type II DM, CHF, and AFib with an insulin lispro sliding scale order; the third had fractures, Parkinson's disease, and dementia with a daily vitamin C order. Surveyors identified 3 errors in 38 opportunities, for a 7.89% error rate.
Medication administration errors occurred when an LPN gave insulin to two residents without priming the injection pens first, resulting in incorrect dosing. One resident had type II DM, cirrhosis, an above-knee amputation, and CKD stage 3, and the other had type II DM, CHF, and AFib. The LPN also reported being unable to locate ordered ascorbic acid for another resident, resulting in an omitted medication.
Two residents in an LTC facility were affected by medication administration errors. One resident received an excessive dose of Celexa due to a failure to discontinue a previous order, while another resident did not receive an increased dose of Seroquel as ordered by the physician. These errors were confirmed by facility staff.
A facility failed to provide necessary dental services to a resident with multiple health conditions, including diabetes and heart disease. The resident, who was cognitively intact and required assistance with ADLs, had no dental care plan or progress notes in their medical record. Interviews confirmed the resident had not seen a dentist since admission, despite expressing a need for dental care. The facility's policy required routine dental services, which were not provided.
Failure to Implement Post-Fall and Care-Planned Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that post-fall interventions and care-planned fall-prevention measures were in place for one resident with a history of multiple recent falls. The resident had Alzheimer’s disease, dementia, Type II diabetes, chronic kidney disease, and multiple sclerosis, with a BIMS score of six indicating severe cognitive deficits, and was dependent on one to two staff for ADLs and used a wheelchair for mobility. The care plan listed fall interventions including keeping the call light within reach, use of non-skid footwear, and a wedge cushion in the wheelchair for safety and positioning. Post-fall investigative summaries documented three unwitnessed falls within a short period, each with new interventions ordered: lowering the back part of the wheelchair seat to inhibit self-transfers after one fall, providing a reacher/grabber tool after another fall, and adding non-skid strips to the floor in front of the bed after a subsequent fall. Despite these identified interventions, surveyor observations and staff interviews showed that the interventions were not in place at the time of the survey. The resident, described by staff as very confused and needing reminders not to stand, walk, or transfer alone, was observed sitting in a wheelchair without a wedge cushion and with the back of the wheelchair not lowered, contrary to the post-fall plan. Maintenance staff confirmed the wheelchair back was not lowered and there was no wedge cushion in use. The DON, RN, and Administrator were initially unable to locate the reacher/grabber tool in the resident’s room, and the DON confirmed there were no non-skid strips in front of the resident’s bed; the reacher/grabber was later found in the closet on a top shelf under blankets, out of the resident’s reach. The facility’s Falls Management Program Policy stated that caregivers would observe residents during daily care to ensure safety and fall-prevention measures listed in the care plan were in place, but this was not carried out for this resident.
PASARR Not Updated for New Psychotic Diagnoses
Penalty
Summary
The facility failed to ensure PASARR screenings were completed and updated to reflect new qualifying diagnoses for two residents reviewed for PASARR accuracy. For one resident, the medical record showed an admission with diagnoses including acute and chronic respiratory failure with hypoxia, CHF, type II DM, atrial fibrillation, mild cognitive impairment of unknown etiology, dysphagia, generalized anxiety disorder, drug induced subacute dyskinesia, major depressive disorder, fibromyalgia, and an additional diagnosis of unspecified psychosis not due to a substance or known physiological condition with an onset date of 09/26/23. The MDS also listed anxiety disorder, depression, and psychotic disorder, but the PASARR Identification Screen dated 01/11/24 only identified mood behaviors and panic or other severe anxiety disorder, with no indication of serious mental illness or developmental disability. The SSL confirmed that other psychotic disorder was not captured in section E of the PASARR and should have been included based on the resident’s medical diagnoses. For the second resident, the record showed diagnoses including seizures, aortic valve stenosis, CKD, osteoarthritis, Alzheimer's disease, dementia, secondary Parkinsonism, convulsions, psychotic disorder, and anxiety, with a new diagnosis of psychotic disorder with delusions and hallucinations added later. The quarterly MDS documented severely impaired cognition, but the most recent PASARR documentation was completed prior to admission and there was no further documentation reflecting the added diagnosis. The DON verified that a new PASARR had not been completed after the new diagnosis was added.
Failure to Develop Care Plan for Resident with Alzheimer’s Disease and Dementia
Penalty
Summary
The facility failed to develop a care plan for a resident with diagnoses of Alzheimer's disease and dementia. Resident #5 was admitted with multiple diagnoses including 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. The resident's diagnoses showed Alzheimer's disease and dementia were added as new diagnoses on 12/01/25, and the quarterly MDS assessment documented severely impaired cognition. Review of the resident's comprehensive care plan, last revised on 12/17/25, showed no care plan in place to address the resident's care needs related to Alzheimer's disease and dementia. The DON verified on 12/30/25 that the facility did not develop a care plan to address those needs.
Delayed Treatment of UTI
Penalty
Summary
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections was not met when the facility failed to provide prompt treatment for a urinary tract infection for Resident #14. The resident was admitted with diagnoses including left femur fracture, anemia, acute respiratory failure, chronic kidney disease, falls, congestive heart failure, obesity, depression, gastro-esophageal reflux disease, and polyneuropathy. The MDS showed no cognitive impairment, with the resident occasionally incontinent of bladder and frequently incontinent of bowel. On 12/22/25, the resident began complaining of dysuria, and a urinalysis with culture and sensitivity was ordered. A urine specimen was collected on 12/24/25 and laboratory results were received on 12/26/25, with the resident, family, and medical professional notified. On 12/27/25, the resident's daughter reported that the results had been reviewed in the electronic medical record and that no antibiotics had been started for the positive UTI. An antibiotic order for Bactrim DS 800-160 mg twice daily for seven days was obtained that day, and the first dose was given that evening. The resident and daughter stated treatment had been delayed more than five days from the start of symptoms, and the DON verified there was a delay in treatment and that antibiotics should have been initiated sooner after the resident began complaining of symptoms.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered to maintain a medication error rate below 5%. Surveyors identified 3 medication errors out of 38 opportunities, for a medication error rate of 7.89%, affecting 3 of 5 residents observed during medication administration. The errors involved Resident #8, Resident #20, and Resident #34. Resident #8 had diagnoses including type II diabetes mellitus, cirrhosis of the liver, acquired absence of the right leg above the knee, and chronic kidney disease stage three, and had an order for insulin aspart 3 units SQ before meals with instructions to hold for a blood glucose level less than 200 mg/dL. During observation, the LPN obtained a blood glucose reading of 245 mg/dL, prepared the insulin, and administered it without priming the injector pen first. Resident #34 had diagnoses including type II diabetes mellitus, chronic diastolic heart failure, and atrial fibrillation, and had an order for insulin lispro sliding scale SQ via injection pen. During observation, the LPN obtained a blood glucose reading of 285 mg/dL, determined 12 units were needed, and administered the insulin without priming the injector pen. Resident #20 had diagnoses including fracture of an unspecified part of the left femur, fracture of the right pubis, Parkinson's disease, and dementia, and had an order for ascorbic acid 100 mg by mouth daily. During medication administration, the ascorbic acid was not available and was omitted while the other scheduled medications were given.
Medication Administration Errors with Insulin Pens
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in significant medication errors during observed medication administration. Resident #8, who had diagnoses including type II diabetes mellitus, cirrhosis of the liver, acquired absence of the right leg above the knee, and chronic kidney disease stage three, had an order for insulin aspart 3 units SQ before meals with instructions to hold if blood glucose was less than 200 mg/dL. During observation, the LPN obtained a blood glucose reading of 245 mg/dL, prepared the insulin, and administered it without priming the injector pen first. Resident #34, who had diagnoses including type II diabetes mellitus, chronic diastolic heart failure, and atrial fibrillation, had an order for insulin lispro sliding scale insulin via injection pen. During observation, the LPN obtained a blood glucose reading of 285 mg/dL, determined the resident required 12 units, and administered the insulin without priming the injector pen first. During interview, the LPN confirmed the insulin pens for both residents were not primed prior to administration and should have been, resulting in an incorrect dose being administered. The LPN also stated she could not locate the ordered ascorbic acid for Resident #20, resulting in an omitted medication.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician, affecting two residents. For Resident #22, who had diagnoses including dementia, diabetes, and depression, a pharmacist recommended reducing the Celexa dose from 20 mg to 10 mg, which the physician agreed to. However, after the resident exhibited uncontrollable crying, the physician ordered the dose to be increased back to 20 mg. Despite this, the resident received both 10 mg and 20 mg doses daily from October 14 to October 30, as confirmed by the Unit Manager. The order for the 10 mg dose should have been discontinued when the 20 mg dose was reinstated. For Resident #28, who had diagnoses including dementia with behavioral disturbances and psychosis, the physician ordered an increase in Seroquel from 25 mg once daily to 25 mg twice daily. However, this change was never implemented, as confirmed by the Director of Nursing. The facility's policy on medication administration, dated June 2014, states that medications should be administered as ordered by the physician, which was not followed in this case.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that residents received necessary and routine dental services, specifically affecting one resident. The medical record for the resident, who was admitted with diagnoses including paroxysmal atrial fibrillation, diabetes mellitus type two, hypertensive heart disease, and depression, did not include a care plan for dental or oral care. The Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and required assistance with activities of daily living. Despite this, there were no dental progress notes in the resident's medical record. Interviews with the resident and the Social Services Leader confirmed that the resident had not seen a dentist since admission to the facility, and the resident expressed a desire to see a dentist due to poor dental health. The facility's policy, dated November 2016, stated that routine ancillary services, including dental care, were to be provided, yet this was not adhered to in the case of the resident.
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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.
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Nursing homes near Chillicothe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westmoreland Place | 0.7 mi | ★★★★★ | 0 | 0 |
| Hopewell Grove Rehabilitation And Healthcare | 2.1 mi | ★★★★★ | 10 | 1 |
| Chillicothe Post Acute | 2.9 mi | ★★★★★ | 1 | 0 |
| Vineyards At Concord, The | 10.7 mi | ★★★★★ | 8 | 0 |
| Embassy Of Valley View | 12.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.