Cycle 1
Health 2024-07-18 · Fire 2024-07-18
13 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Chillicothe, OH
Chillicothe Post Acute
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1058 Columbus St, Chillicothe, OH
(740) 773-5000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1982-02-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
2.37
CMS adjusted total nurse staffing hours
Case-mix index
1.93
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,108
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.56
Baseline 19.60% · Performance 19.32% · Measure score 4.56 · Achievement 4.56 · Improvement 0.60
Healthcare-associated infections
3.06
Baseline 8.40% · Performance 7.19% · Measure score 3.06 · Achievement 2.17 · Improvement 3.06
Total nurse turnover
3.49
Baseline 55.26% · Performance 49.40% · Measure score 3.49 · Achievement 3.49 · Improvement 1.43
Adjusted total nurse staffing
0
Baseline 2.95 hours · Performance 2.95 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.06% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 12.77% · Lower 95% interval 8% |
| Discharge to community | 51.31% |
50.57%
0.7 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 46.91% · Lower 95% interval 41.11% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 64 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 78.05% |
53.69%
24.4 pts better
|
Numerator 32 · Denominator 41 |
| Discharge mobility score | 60.98% |
50.94%
10 pts better
|
Numerator 25 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 1.56% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 64 · Adjusted rate 1.15% |
| Healthcare-associated infections requiring hospitalization | 7.19% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 7.84% · Lower 95% interval 3.78% |
| Staff COVID-19 vaccination coverage | 0.83% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 120 |
| Staff flu vaccination coverage | 31.15% |
42%
10.9 pts worse
|
Numerator 38 · Denominator 122 |
| Discharge function score | 75.61% |
56.45%
19.2 pts better
|
Numerator 31 · Denominator 41 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 30 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 21.05% |
25.2%
4.1 pts worse
|
Numerator 8 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.8
1.2 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
92.4%
7.2 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.4% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
94.5%
4.2 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.3%
3.1 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.1% · Q3 7.4% · Q4 6.5% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 49.8% |
26.1%
23.7 pts worse
|
11.4%
38.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 30.6% · Q3 54.8% · Q4 89.5% · 4Q avg 49.8% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
6.2%
3.1 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.0% · Q3 8.9% · Q4 18.0% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.2% |
25.4%
1.2 pts better
|
19.6%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 17.6% · Q3 26.8% · Q4 28.0% · 4Q avg 24.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.8% |
11.5%
6.7 pts better
|
16.7%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 2.4% · Q3 4.4% · Q4 2.7% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.8% |
7.7%
0.1 pts worse
|
16.3%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 15.1% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.5% |
6.2%
0.3 pts worse
|
14.9%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.3% · Q3 7.4% · Q4 6.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
0.5%
0.6 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 1.5% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
21.7%
0.7 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 18.6% · Q3 25.7% · Q4 26.0% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
3.7%
0.9 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.7% · Q3 0.9% · Q4 2.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.6% |
78.1%
9.5 pts worse
|
81.7%
13.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.7% · Q2 75.9% · Q3 60.7% · Q4 47.1% · 4Q avg 68.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
12.5%
0.2 pts better
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 12.9% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.0% |
75.6%
16.6 pts worse
|
79.7%
20.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.9% |
25.1%
6.2 pts better
|
23.9%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 19.4% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-09 · Fire 2022-05-09
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-08-08 · Fire 2019-08-08
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-18
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-19
F · Potential for more than minimal harm
2022-05-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-06-17
F · Potential for more than minimal harm
2019-08-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-09-17
F · Potential for more than minimal harm
2019-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-17
F · Potential for more than minimal harm
2019-08-08
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2019-09-17
F · Potential for more than minimal harm
2019-08-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-09-17
E · Potential for more than minimal harm
2019-08-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-09-17
E · Potential for more than minimal harm
2019-08-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-09-17
E · Potential for more than minimal harm
2019-08-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-09-17
E · Potential for more than minimal harm
2019-08-08
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-09-17
E · Potential for more than minimal harm
2019-08-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-09-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-19
E · Potential for more than minimal harm
2024-07-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-18
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-18
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-18
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-18
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-08-19
D · Potential for more than minimal harm
2023-06-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-06-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-05-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-18
E · Potential for more than minimal harm
2022-05-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-09
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-09
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-06-17
C · Minimal harm
2022-05-09
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2022-06-17
F · Potential for more than minimal harm
2019-08-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2019-09-17
E · Potential for more than minimal harm
2019-08-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-09-17
D · Potential for more than minimal harm
2019-08-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-09-17
D · Potential for more than minimal harm
2019-08-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-09-17
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Dixon, David
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Nh, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Hopewell Grove Rehabilitation and Healthcare
Chillicothe, OH
1-star overall rating with 2-star inspections with $32,380 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Westmoreland Place
Chillicothe, OH
1-star overall rating with 1-star inspections with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
National Church Residences Chillicothe
Chillicothe, OH
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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