A list of the most recent deficiencies for Signature Healthcare of Chillicothe. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-04-27 | 2023-06-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-27 | 2023-06-08 | N |
| 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. | Health | 2023-04-27 | 2023-06-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-06-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-27 | 2023-06-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-27 | 2023-06-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-27 | 2023-06-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-25 | 2023-06-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-25 | 2023-06-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-25 | 2023-06-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-25 | 2023-06-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-06-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-25 | 2023-06-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-25 | 2023-06-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-25 | 2023-06-08 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-04-25 | 2023-06-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-24 | 2021-06-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-24 | 2021-06-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-24 | 2021-06-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-24 | 2021-06-25 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-24 | 2021-06-25 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-05-24 | 2021-06-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-24 | 2021-06-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-05-24 | 2021-06-25 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-05-24 | 2021-06-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-05-24 | 2021-06-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-24 | 2021-06-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-24 | 2021-06-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-24 | 2021-06-25 | N |
| 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. | Health | 2021-05-24 | 2021-06-25 | N |
| 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. | Health | 2021-05-24 | 2021-06-25 | N |
| Provide or obtain dental services for each resident. | Health | 2021-05-24 | 2021-06-25 | N |
| Meet other general requirements. | Fire Safety | 2021-05-24 | 2021-06-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-24 | 2021-06-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-24 | 2021-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-18 | 2021-05-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-01-31 | 2019-03-08 | N |
| 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. | Health | 2019-01-31 | 2019-03-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-31 | 2019-03-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-01-31 | 2019-03-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-31 | 2019-03-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-31 | 2019-03-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-31 | 2019-03-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-31 | 2019-03-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-31 | 2019-03-08 | N |
| 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. | Health | 2019-01-31 | 2019-03-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-31 | 2019-03-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-31 | 2019-03-08 | N |
| Dispose of garbage and refuse properly. | Health | 2019-01-31 | 2019-03-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-31 | 2019-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-31 | 2019-03-08 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-01-31 | 2019-03-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-01-28 | 2019-03-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-01-28 | 2019-03-08 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-01-28 | 2019-03-08 | N |
