Cycle 1
Health 2025-02-27 · Fire 2025-02-27
21 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Chillicothe, MO
Grand River Health Care
1-star overall rating with 1-star inspections with abuse icon flag with $63,001 in total fines with 21 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
118 Trenton Road, Chillicothe, MO
(660) 646-0353
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
28
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
James & Judy Lincoln
Operator or chain grouping
Approved since
1992-01-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
58 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 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
0.77
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.96
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.74
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
0.94
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
85%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,885
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.99
Baseline 60.00% · Performance 47.37% · Measure score 3.99 · Achievement 3.99 · Improvement 3.09
Adjusted total nurse staffing
2.30
Baseline 4.15 hours · Performance 3.73 hours · Measure score 2.30 · Achievement 2.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 2.5% |
8.2%
5.7 pts worse
|
Numerator 1 · Denominator 40 |
| Staff flu vaccination coverage | 8% |
42%
34 pts worse
|
Numerator 6 · Denominator 75 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 2.8% |
84.8%
82 pts worse
|
93.4%
90.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
90.9%
5.7 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.1%
4.1 pts better
|
3.3%
3.3 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 who have depressive symptoms | 0.0% |
14.7%
14.7 pts better
|
11.4%
11.4 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 who lose too much weight | 3.3% |
5.5%
2.2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.7% · Q3 0.0% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 57.6% |
25.3%
32.3 pts worse
|
19.6%
38 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 60.0% · Q2 56.5% · Q3 63.6% · Q4 50.0% · 4Q avg 57.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 80.0% |
25.0%
55 pts worse
|
16.7%
63.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 80.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 6.3% |
20.3%
14 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.0% |
19.8%
7.8 pts better
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 13.0% · Q3 9.1% · Q4 13.6% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.4%
0.4 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
2.6%
0.2 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.7% · Q3 4.0% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.6% |
18.1%
9.5 pts better
|
19.8%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.8% · Q3 3.5% · Q4 21.8% · 4Q avg 8.6% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.0%
1 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 11.0% · Q3 0.0% · Q4 0.0% · 4Q avg 4.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-24 · Fire 2023-04-24
19 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2021-02-10 · Fire 2021-02-10
20 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-07
F · Potential for more than minimal harm
2023-04-24
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-04-24
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-04-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-17
F · Potential for more than minimal harm
2023-04-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-04-24
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-04-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-04-24
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-04-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-04-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-04-24
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-04-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-30
F · Potential for more than minimal harm
2021-02-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-05-18
F · Potential for more than minimal harm
2021-02-10
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 2021-03-06
F · Potential for more than minimal harm
2021-02-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-05-18
E · Potential for more than minimal harm
2021-02-10
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-03-06
E · Potential for more than minimal harm
2021-02-10
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2021-05-18
E · Potential for more than minimal harm
2021-02-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-03-06
E · Potential for more than minimal harm
2021-02-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-03-06
E · Potential for more than minimal harm
2021-02-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-03-06
E · Potential for more than minimal harm
2021-02-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-03-06
E · Potential for more than minimal harm
2021-02-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-03-06
E · Potential for more than minimal harm
2021-02-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-03-06
E · Potential for more than minimal harm
2021-02-10
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 2021-05-18
E · Potential for more than minimal harm
2021-02-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-05-18
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
D · Potential for more than minimal harm
2026-01-09
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.
Not marked corrected
D · Potential for more than minimal harm
2025-11-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-30
G · Actual harm
2025-03-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-25
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-25
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 2025-04-22
F · Potential for more than minimal harm
2025-02-27
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 2025-04-07
E · Potential for more than minimal harm
2025-02-27
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 2025-04-07
E · Potential for more than minimal harm
2025-02-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
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 2025-04-07
E · Potential for more than minimal harm
2025-02-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-07
G · Actual harm
2024-12-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-10
G · Actual harm
2024-12-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
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 2024-12-27
D · Potential for more than minimal harm
2024-09-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-10-11
F · Potential for more than minimal harm
2023-04-24
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 2023-06-06
E · Potential for more than minimal harm
2023-04-24
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 2023-06-06
E · Potential for more than minimal harm
2023-04-24
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-04-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-04-24
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 2023-06-06
E · Potential for more than minimal harm
2023-04-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-04-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-04-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-27
E · Potential for more than minimal harm
2023-04-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-24
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-24
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 2023-06-06
D · Potential for more than minimal harm
2023-04-24
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-07-27
E · Potential for more than minimal harm
2021-02-10
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-05-18
E · Potential for more than minimal harm
2021-02-10
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-05-18
E · Potential for more than minimal harm
2021-02-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-03-06
E · Potential for more than minimal harm
2021-02-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-05-18
E · Potential for more than minimal harm
2021-02-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
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 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-05-18
D · Potential for more than minimal harm
2021-02-10
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-05-18
D · Potential for more than minimal harm
2021-02-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
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 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
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 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
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 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-03-06
Penalties and ownership
What sits behind the stars
$36,390
2026-01-09
Fine
Fine · fine $36,390
Fine
$26,611
2024-12-05
Fine
Fine · fine $26,611
Fine
$0
2024-12-05
Payment Denial
Payment Denial · denial start 2025-01-08 · 2 days
2 day denial
$0
2023-04-24
Payment Denial
Payment Denial · denial start 2023-07-24 · 24 days
24 day denial
Ownership
Lincoln, James
5% Or Greater Direct Ownership Interest · Individual
Lincoln, Judy
5% Or Greater Direct Ownership Interest · Individual
Crane, Gary
Corporate Director · Individual
Drake, Timothy
Corporate Officer · Individual
Lauhoff, Kent
W-2 Managing Employee · Individual
N & R Of Chillicothe, Inc.
Operational/Managerial Control · Organization
Stutts, Charlotte
Corporate Officer · Individual
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