Arc at Chillicothe

In the surveyor’s words

From the most serious findings on record at Arc at Chillicothe, in the surveyor’s own words.

• Immediate jeopardy, isolatedF635May 27, 2022

  Based on interview and record review, the facility failed to ensure new admission Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 not receiving diabetic monitoring or medically necessary insulin which resulted in R1 vomiting, becoming unresponsive with absence of pulse and respirations, requiring CPR (cardiopulmonary resuscitation) initiation, transferring to the local hospital, and subsequently expiring. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 while the facility is in the process of educating, auditing and monitoring all new admissions for clarification of all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF684May 27, 2022

  Based on interview and record review, the facility failed to clarify an admission Physician order, perform diabetic monitoring and ensure necessary equipment and medication were available for one (R1) of three residents reviewed for diabetic care in the sample of three. These failures resulted in R1's blood sugar not being monitored, R1 not having an insulin pump for insulin medication and R1 not receiving medically necessary insulin by other means subsequently resulting R1's blood sugar level becoming elevated, and R1 becoming unresponsive without a pulse or respirations, CPR (cardiopulmonary resuscitation) being initiated, R1 being transferred to the local hospital and R1 expiring due to Diabetic Ketoacidosis. These failures resulted in an Immediate Jeopardy. […]

• Actual harm, isolatedF686Apr 22, 2026

  Based on observation, interview, and record review, the facility failed to ensure a resident with a risk for skin breakdown received accurate skin assessments to identify a newly acquired pressure injury, provide a pressure injury treatment and physician notification promptly and ensure interventions were implemented timely and followed to prevent further injury to an unstageable pressure ulcer for one of four residents (R28) reviewed for pressure ulcers in the sample of 35. This failure resulted in R28 returning from the hospital with an unstageable pressure injury and going five days without a wound treatment order, physician notification, or any wound assessments. […]

• Actual harm, isolatedF580May 27, 2022

  Based on interview and record review, the facility failed to notify the Physician of a change in a resident's condition for one (R1) of three residents reviewed for diabetic care in the sample of three. These failures resulted in R1 experiencing increased thirst, increased urination and vomiting which led to the continual decline in R1's condition leading to R1's unresponsiveness, absence of pulse and respiration, initiation of cardiopulmonary resuscitation, transfer to the local hospital and subsequent death. Findings include: The facility policy and procedure for Physician Notification of Change in Resident Condition, Revised 4/2019, documents, Staff observe, document and communicate to the Physician, changes in resident condition promptly. […]

• No harm, potential for more than minimal, widespreadF585Apr 22, 2026

  Based on observation, record review and interview, the facility failed to provide readily available grievance forms and failed to post grievance/complaint procedures in a prominent location throughout the facility. This has the potential to affect all 89 residents residing in the facility. The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 4/20/26 and signed by V1 (Administrator), documents 89 residents reside within the facility.On 4/21/2026 at 10:37 AM R15, R27, R37, R84, and R87 all stated they have never been shown how to fill out a grievance, where the grievance forms are located, how to fill one out anonymously, or who the grievance official is to turn the forms into.On 4/21/26 at 11:00 AM a tour was conducted with V1/Administrator asking V1 to show where… […]