Arc at Chillicothe

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on Record Review and Interview, the facility failed to ensure residents and/or resident families are provided with a written notice of transfer when being transferred to the hospital. This failure has the potential to affect all 89 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to offer bedtime snacks to six of six residents (R15, R27, R37, R84, and R87) reviewed for bedtime snacks in the sample of 35.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to report allegations of staff to resident mental abuse and neglect to the facility's abuse coordinator and the state agency for three of four residents (R13, R39, R72) reviewed for abuse in the sample of 35.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to ensure an abuse investigation was conducted and residents were protected from alleged perpetrators of mental abuse and neglect for three of four residents (R13, R39, R72) reviewed for abuse in the sample of 35.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to ensure a residents Minnimum Data Set (MDS) assessments were completed accurately to reflect insulin usage for one of 24 residents (R2) reviewed for MDS accuracy in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's fingernails were kept clean and trimmed for one of one resident (R60) reviewed for ADLs (Activities of Daily Living) in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to implement a range of motion program for two of two residents (R7 and R14), with known functional limitations, in a sample of 35. 1. R7's facility admission record documents that R7 was admitted to the facility on [DATE] with the following diagnoses: Relapsing-Remitting Multiple Sclerosis, Paraplegia, Muscle Wasting and Atrophy. R7's current Physician Order Sheet, dated April 2026 includes the following physician orders: No Weight Bearing to the right lower extremity; Ankle brace to the right ankle. R7's current Restorative Assessment, dated 2/9/26 documents R7 requires staff assistance for all activities of daily living, would benefit from a range of motion program, has a functional limitation in the bilateral upper and lower extremities and has paralysis in the bilateral upper and lower extremities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to check gastric tube feeding residual prior to administering an enteral feeding for two of two residents (R9 and R34) reviewed for gastric tube feedings in a sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to don the required personal protective equipment during high-contact care for two of five residents (R11 and R34) reviewed for infection control in a sample of 35.

Inspectors wroteBased on interview, and record review, the facility failed to prevent abuse for two (R7 and R8) of three residents reviewed for abuse in a sample of eight.

Inspectors wroteBased on record review and interview the facility failed to ensure the resident's environment was free of hazards to prevent falls for one of three residents (R1) reviewed for accidents in the sample of five.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure laboratory testing was completed as ordered for 1 of 1 residents reviewed for medical testing in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to ensure diagnostic testing results were reported and reviewed in a timely manner for 1 of 1 residents reviewed for medical testing in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff completely covered hair in a sanitary manner while in the kitchen; and failed to ensure a chemical product was not stored in an unlocked lower cabinet in the dining room. These failures have the potential to affect 89 of the 90 residents who consume food in the facility (R75 was nothing by mouth/NPO).

Inspectors wroteBased on record review, observation and interview the facility failed to secure a controlled substance medication in a double-locked location for one of one resident (R74) reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's annual State Survey Results were readily and easily accessible to residents for review. This failure has the potential to affect all 90 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to apply the correct treatment to a wound for one (R6) of three residents reviewed for wounds in a sample list of seven.

Inspectors wroteBased on interview and record review the facility failed to obtain a urinalysis in a timely manner for one of three residents (R1) reviewed for urinary tract infections in the sample of seven. Findings Include: R1's Medical Diagnoses list dated 6/18/2024 documents Acute Kidney Failure, Type 2 Diabetes Mellitus with Hyperglycemia, Difficulty in Walking, and Lack of Coordination. R1's Physician Order written by V13 (R1's physician) dated 6/28/24 documents an order for a urinalysis. R1's Lab Services Urine Microbiology Results dated 7/5/24 document R1's urine was collected on 7/2/23 at 6:45 PM and was sent to the lab on 7/3/24 at 11:24 AM. R1's urine's microbiology results detected Escherichia coli Extended Spectrum Beta-Lactamase (ESBL) 50-100,000 colonies per milliliter. On 8/21/24 at 2:00 PM, V2 Director of Nursing confirmed R1 had received a physician order for a urinalysis. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene and cleanse buttocks wound during wound care for one of three residents (R1) reviewed for wound care in a sample of three.

Inspectors wroteBased on observation, interview and record review the facility failed to offer palatable meals. This failure has the potential to affect 80 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene and change gloves during meal service. This has the potential to affect 80 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with scheduled showers for two of two residents (R28, R323) reviewed for hygiene in the sample of 42.

Inspectors wroteBased on observation interview and record review the facility failed to maintain aseptic technique during wound care for one of one resident (R274) reviewed for wound care in a sample of 42.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a range of motion program was in place for a resident with functional limitations in range of motion for one of four residents (R64) reviewed for range of motion in the sample of 42.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a urinary catheter drainage bag was in a privacy bag and secured to prevent contact with the floor for one of one resident (R274) reviewed for urinary catheters in a sample of 42.

Inspectors wroteBased on observation, interview and record review, facility staff failed to administer feeding tube flushes as required for one of one resident (R175) reviewed for feeding tubes in a sample of 42.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ongoing communication with the dialysis center and failed to develop a complete comprehensive care plan for one of one resident (R177) reviewed for dialysis, in a sample of 42.

Inspectors wroteBased on observation, interview and record review, the facility failed to document an appropriate medical indication for the use of an Antipsychotic medication for one resident (R36) and failed to identify and monitor for target behaviors that warrant the use of an Antipsychotic medication for two of three residents (R36 and R39) reviewed for psychotropic medications in the sample of 42.