Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Chillicothe Post Acute during CMS and state inspections, most recent first.
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.
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.
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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) |
|---|---|---|---|---|
| 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 | — | 8 | 0 |
| National Church Residences Bristol Village | 13.9 mi | — | 0 | 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 August 2026) and official state health department websites.