Cycle 1
Health 2024-10-31 · Fire 2024-10-31
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Chillicothe, OH
National Church Residences Chillicothe
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
142 University Drive, Chillicothe, OH
(740) 773-8107
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
48
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-02-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.76
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
76%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,253
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.50% · Performance 22.62% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.34% · Performance 9.35% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.79
Baseline 63.83% · Performance 60.47% · Measure score 0.79 · Achievement 0.79 · Improvement 0.36
Adjusted total nurse staffing
2.08
Baseline 3.96 hours · Performance 3.67 hours · Measure score 2.08 · Achievement 2.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 7.55% · Lower 95% interval 6.81% |
| Discharge to community | 68.11% |
50.57%
17.5 pts better
|
Better than the National Rate · Eligible stays 140 · Observed rate 70.71% · Lower 95% interval 60.77% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 84 · Denominator 84 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 84 |
| Discharge self-care score | 52.54% |
53.69%
1.1 pts worse
|
Numerator 31 · Denominator 59 |
| Discharge mobility score | 62.71% |
50.94%
11.8 pts better
|
Numerator 37 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 1.19% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 84 · Adjusted rate 1.05% |
| Healthcare-associated infections requiring hospitalization | 9.35% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 11.25% · Lower 95% interval 5.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 59 |
| Staff flu vaccination coverage | 3.85% |
42%
38.1 pts worse
|
Numerator 6 · Denominator 156 |
| Discharge function score | 67.8% |
56.45%
11.3 pts better
|
Numerator 40 · Denominator 59 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 45 · Denominator 45 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 30.56% |
25.2%
5.4 pts better
|
Numerator 11 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.1% |
3.3%
4.8 pts worse
|
3.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 12.0% · Q3 4.8% · Q4 3.8% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
26.1%
22.6 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
6.2%
0.4 pts better
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.0% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
25.4%
11.5 pts better
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 19.0% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
11.5%
1.2 pts worse
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.7% · 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 | 10.0% |
7.7%
2.3 pts worse
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.8% |
6.2%
3.4 pts better
|
14.9%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.5% · 4Q avg 2.8% · 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% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
0.5%
1.6 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.1% |
21.7%
0.6 pts better
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 25.5% · Q4 23.4% · 4Q avg 21.1% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
78.1%
18.8 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 97.0% · Q3 97.2% · Q4 96.2% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
12.5%
1 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 10.0% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.4% · Q4 1.5% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
75.6%
19.4 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
25.1%
0.4 pts better
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 21.4% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-13 · Fire 2022-05-13
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-05-16 · Fire 2019-05-16
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-31
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-27
F · Potential for more than minimal harm
2022-05-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-01
E · Potential for more than minimal harm
2022-05-13
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-07-01
E · Potential for more than minimal harm
2022-05-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-01
E · Potential for more than minimal harm
2022-05-13
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-07-01
F · Potential for more than minimal harm
2019-05-16
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 2019-06-21
F · Potential for more than minimal harm
2019-05-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-06-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-31
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-11-27
E · Potential for more than minimal harm
2023-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-11-06
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 2023-11-27
D · Potential for more than minimal harm
2023-11-06
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 2023-11-27
D · Potential for more than minimal harm
2022-05-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-05-13
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 2022-07-01
D · Potential for more than minimal harm
2019-05-16
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 2019-06-21
Penalties and ownership
What sits behind the stars
Ownership
Alexander, Sean
Corporate Officer · Individual
Anderson, Denise
Corporate Director · Individual
Brown, Sonya
Corporate Director · Individual
Dehring, Lindsey
Corporate Director · Individual
Dehring, Lindsey
Corporate Officer · Individual
Jenkins, Anna
Corporate Director · Individual
Mettler, Brianna
Operational/Managerial Control · Individual
Mettler, Brianna
Corporate Director · Individual
Mettler, Brianna
Corporate Officer · Individual
Meyung, Kelli
Corporate Officer · Individual
National Church Residences
Operational/Managerial Control · Organization
National Church Residences Health Care
Operational/Managerial Control · Organization
Rule, Matthew
Corporate Director · Individual
Rule, Matthew
Corporate Officer · Individual
Stitzer, Parker
Corporate Director · Individual
Woolley, Julie
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
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
#2
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
#3
Chillicothe Post Acute
Chillicothe, OH
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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