Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Circleville Post-acute during CMS and state inspections, most recent first.
PTAC units serving two residents and the main dining area were observed with dust, dirt, and snack chips in the air vents and grates. Staff gave differing accounts of who cleaned the units and how often, with housekeeping describing weekly filter wiping and maintenance describing annual internal cleaning. Housekeeping records did not specifically include the dining room vents, and the Maintenance Director acknowledged the debris was present.
Cold Food Held at Unsafe Temperature: During lunch service, individually prepared fruit cups were found at 44 degrees F in the kitchen, and a later test tray check showed a fruit cup at 63 degrees F. Dietary staff said they did not check the temperature before tray service and stated they did not know they had to. Food temperature logs showed cold items were rarely checked, and the facility policy required PHF/TCS foods to be held at or below 41 degrees F.
Expired food items, open dry goods, and improperly stored kitchen supplies were found in the kitchen, along with a dirty ice machine and dust-coated utensil rack. Staff also handled food without proper hand hygiene, including a dietary staff member who continued tray line service after touching eyeglasses and a CNA who used bare hands on a resident’s food and used a sugar packet picked up from the floor.
A CNA with a documented history of poor customer service and unprofessional behavior repeatedly used a rude, loud, and disrespectful tone toward residents and staff, including telling a resident that if she could not be patient she would be moved to a “bad hall” where it would take longer to receive help. Staff, including an LPN and a unit manager, reported witnessing the CNA raising her voice in hallways, yelling in the halls and at the nurses’ station, and making loud, demeaning comments about a resident who refused a shower. These actions occurred despite a facility policy requiring immediate reporting of suspected abuse or neglect to administration and state authorities.
Failure to Report Suspected Verbal Abuse: A resident reported that a CNA had been mean and disrespectful, including making a threatening comment about moving her to the bad hall if she could not be patient. The Administrator spoke with the resident and treated the issue as poor customer service, and no SRI was submitted. The CNA had a documented pattern of rude, unprofessional behavior toward residents and staff, and facility policy required suspected abuse to be reported immediately to the state agency.
Failure to thoroughly investigate an allegation of verbal abuse involving a CNA and a resident. The resident reported that the CNA had been mean and made a threatening remark about being moved to the "bad hall" when help was requested. The facility did not create an SRI, and records showed the CNA had prior corrective actions for rude, disrespectful, and unprofessional behavior toward residents and staff. An LPN, the Unit Manager, and another LPN all described similar concerns about the CNA’s tone, yelling, and disrespectful comments.
Pureed Diet Prepared to Improper Texture: A dietary staff member served chipped beef and gravy puree that still contained larger meat pieces for residents on a pureed diet. The staff member did not taste the food to check texture, and the DON was observed advising the staff member to puree it longer before a smoother texture was later seen.
Failure to Ensure Appropriate Antibiotic Use: Surveyors found that antibiotics were ordered or continued for multiple residents despite urine cultures showing low colony counts or antibiotics not listed as sensitive on the culture report. One resident had altered mental status only, another had dysuria with a low-count Proteus culture, and a third was placed on prophylactic Macrobid without a valid indication, while staff and the DON acknowledged the physician did not document the rationale for these antibiotic decisions.
A resident with advanced dementia, poor safety awareness, and a history of sliding out of bed was placed with a body pillow tucked tightly under the fitted sheet at the bed’s edge for safety after a fall. Surveyors observed the pillow in place, and staff confirmed it was used to prevent the resident from scooting out of bed; a MA also confirmed the resident could not remove it on command. The facility policy defined a restraint as a device the resident cannot remove in the same manner it was applied when it restricts typical movement or position changes.
Psychotropic Medication Not Adequately Monitored: A resident with Parkinson's induced psychosis, hallucinations, paranoia, and dyskinesia was receiving pimavanserin, but the facility did not adequately monitor response to treatment. Staff observed the resident with eyes closed much of the day, lethargy, decreased appetite, confusion, and weight loss, yet there was no behavior tracking in place for targeted symptoms such as hallucinations. Interviews confirmed no observed behaviors and no change in involuntary movements since admission.
The facility failed to follow physician orders and notify the MD for three residents. One resident with diabetes did not receive ordered sliding scale insulin after an insulin regimen change, despite a physician progress note indicating sliding scale use. Another resident with CHF had multiple daily and weekly weight changes that met the notification threshold, but the chart lacked documentation that the MD was informed. A third resident with HTN had repeated elevated BP readings, including severe hypertension, and the MD and regional nurse confirmed continued elevations were not communicated as required.
Failure to Monitor a Wandering Resident: A resident with Alzheimer's disease, dementia, and a known history of exit seeking was identified as at risk for elopement and had care plan interventions for alarm checks, redirection, and secured exits. The resident left the secured memory care unit alone while a CNA was caring for another resident, and the CNA did not promptly respond to the alarm or complete a head count. The resident's record also lacked progress note documentation of the incident.
A resident with ESRD, renal dialysis dependence, heart failure, and severe cognitive impairment had an AV fistula in the left arm, with orders and care plan instructions not to use that arm for BP checks, IVs, or blood draws. However, the BP log showed the left arm was used 58 times, and an LPN confirmed multiple instances of BP being taken in the arm with the AV shunt; CNAs also did not normally document which arm was used.
Pharmacy recommendations were not consistently reviewed, acknowledged, or documented by the physician for two residents. One resident had repeated unresolved allergy and epoetin alfa dosing discrepancies, with epoetin alfa given outside the stated hold parameters and no physician documentation explaining the orders. Another resident had ongoing low magnesium results and other medication review issues, but several pharmacy reports were signed by an LPN or DON instead of the physician, and the record lacked evidence of timely physician review or documentation.
A resident with Parkinson’s disease, vascular dementia, CHF, diabetes, malnutrition, dysphagia, and bilateral lower-extremity amputations received Epoetin Alfa outside the ordered parameters. The MAR showed doses were given when Hgb was 10.0, 10.6, and 11.0, even though the order directed the medication to be held when Hgb was greater than 10. The DON confirmed the medication was administered outside the parameters.
Failure to maintain contact precautions and provide proper catheter care. A resident with C. diff was observed out of the room with other residents despite ongoing diarrhea and contact precautions, and staff were unsure how often shared equipment was cleaned. Another resident on contact precautions for ESBL had blood drawn by a contracted phlebotomist without a gown, and catheter care was incomplete because staff cleansed only the catheter tubing and not the labia or urethral meatus; basin water was also poured into the room’s hand sink.
Dirty PTAC Units in Resident Rooms and Dining Area
Penalty
Summary
Facility failed to ensure PTAC units were maintained in a clean manner. Observations of the PTAC air machines serving Resident #39 and Resident #40 showed significant debris in the vents where air blew out, including dust and dozens of coin-sized snack chips. Similar observations in the main dining area found three PTAC machines with thick pieces of dirt and dust in the vent/grates where air exited toward residents. The facility census was 90. During interviews, Resident #40 stated the PTAC machine gets cleaned sometimes. Housekeeping staff stated resident rooms were cleaned daily and that PTAC filters were checked and wiped down on Fridays, while maintenance staff cleaned the internal pieces of the PTAC machine. The Maintenance Director stated PTAC units were cleaned once annually in September according to the manufacturer guide and acknowledged the guide did not give specific timeframes. The Housekeeping Supervisor stated the PTAC machines should be cleaned weekly on Fridays by housekeeping staff, but also stated the vents where the debris was observed were internal and would be cleaned by maintenance. Review of housekeeping check-offs for 05/2026 showed the dining room vents were not specifically included, although the dining room and filter were checked daily. Facility policies stated maintenance shall be provided to all equipment and heating and cooling systems maintained in good condition, and environmental surfaces shall be cleaned or disinfected on a regular basis and when visibly soiled.
Cold Food Held at Unsafe Temperature
Penalty
Summary
Food and drink were not maintained at a palatable and safe temperature during lunch service. On 03/10/26 at 11:35 AM, individually prepared fruit cups were observed sitting on trays in the kitchen, and when Dietary Manager #426 checked them at 11:48 AM, the fruit cups were 44 degrees Fahrenheit. The Dietary Manager then placed the trays of fruit cups in the freezer. Interviews with [NAME] #154 and [NAME] #248 confirmed they did not check the temperature of the fruit cups before lunch tray service and stated, "we didn't know we had to." Review of the facility's food temperature logs for 02/23/25 through 03/20/26 showed cold food item temperatures were checked only on the day of survey after prompting and on 02/16/26. During a test tray temperature check at 12:56 PM, the fruit cup (peaches) measured 63 degrees Fahrenheit. The facility policy stated PHF/TCS foods are to be stored at or below 41 degrees Fahrenheit unless otherwise specified, and defined the danger zone as temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit.
Unsafe food storage and poor kitchen hygiene
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards. During kitchen observations, expired and improperly stored food items were found on shelving near the prep table, including a used bottle of kitchen bouquet browning and seasoning sauce and a gallon of used white wine past their expiration dates. In dry storage, open containers of granulated sugar and flour were observed with lids off, along with multiple unopened expired items such as teriyaki marinade and sauce, kitchen bouquet browning and seasoning sauce, red cooking wine, and white wine. A used container of cream cheese icing was also present with an open date noted and a handwritten expiration date. Dietary staff confirmed the items were expired, and the facility policy required dry foods to be rotated using a first-in, first-out system. Additional observations showed the ice machine outside the kitchen had black substance on the top part and on the right wall above the ice, and the Maintenance Director confirmed those areas were dirty and needed cleaning. The ice machine cleaning log showed the last clean, sanitize, delime, and filter service was completed months earlier, with the last filter cleaning and bin dump/sanitize documented separately. Kitchen utensils stored on a ceiling-mounted metal rack above the prep table were coated with thick dust, and a large whisk had dust and spider webs in its wires. A dietary staff member later used tongs from that dirty rack to handle bread. In tray service and dining observations, one dietary staff member handled eyeglasses, wiped them on a shirt, and continued tray line service without hand hygiene, and a CNA handled a resident’s sausage link with bare hands, picked up a sugar packet from the floor and used it for coffee, and did not perform hand hygiene after either event. The facility’s handwashing policy stated all personnel are expected to adhere to hand hygiene practices to help prevent the spread of infections.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse and to ensure a verbal abuse–free environment. Certified Nursing Aide (CNA) #114 had a documented history of poor customer service and unprofessional behavior, including being rude and negative toward residents and coworkers, as reflected in multiple corrective action and employee counseling forms. On at least two occasions in late 2025, CNA #114 was counseled for failing to maintain respect for residents and for poor customer service. Staff statements described ongoing concerns that CNA #114 used a rude, dismissive, and disrespectful tone with residents and staff, lacked empathy and patience when providing care, and yelled in the hallways. A specific incident involved Resident #75, who reported to the Administrator that CNA #114 had been mean to her since admission. The resident stated that when she asked for help, CNA #114 told her that if she could not learn to be patient, she would be moved to the “bad hall,” where there were more residents and it would take even longer to receive help. Other staff corroborated concerns about CNA #114’s verbal interactions with residents. A typed statement from an LPN described having to verbally educate CNA #114 about her tone of voice toward a resident in a dining room, reminding her that the facility was the residents’ home and that discussions should occur privately due to residents and family members being present. Additional staff statements from a Unit Manager and another LPN detailed observations within the preceding weeks of CNA #114 being loud, rude, and unprofessional toward both residents and staff. The Unit Manager reported witnessing CNA #114 raising her voice in hallways and discussing residents loudly enough for others to overhear, including a comment that a resident who refused a shower “stinks and needs to shower.” Another LPN reported witnessing CNA #114 yelling in the halls and at the nurses’ station on several occasions. The Director of Nursing stated that CNA #114 was no longer allowed to work on a particular unit because she was not allowed to care for a resident there and noted that other staff experienced her as rude and disrespectful when asked to complete tasks. These events occurred despite a facility policy requiring immediate reporting of suspected abuse, neglect, or related concerns to the Administrator and state authorities.
Failure to Report Suspected Verbal Abuse
Penalty
Summary
The facility failed to report suspected verbal abuse to the required state agency after Resident #75 stated that CNA #114 had been mean to her and had spoken to her in a disrespectful manner. The report states that the resident told the Administrator that CNA #114 had been mean since the day she arrived and had told her, if she could not learn to be patient, she would be moved to the bad hall where it would take even longer to get help. The facility did not create or submit a self-reported incident for this event. The record review showed a pattern of concerns involving CNA #114, including multiple corrective action forms for poor customer service, unprofessional behavior, and being rude and negative toward residents and coworkers. Additional statements from an LPN, the Unit Manager, and another LPN described the CNA as loud, rude, disrespectful, and unprofessional toward residents and staff, including raising her voice in hallways and making negative comments about a resident who refused a shower. The Administrator acknowledged that she spoke with Resident #75 and determined the issue was poor customer service, so no self-reported incident was completed. The facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation stated that if resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to the state licensing/certification agency. The report indicates that this required reporting did not occur for the incident involving Resident #75 and CNA #114.
Failure to Thoroughly Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving CNA #114 and one resident. The report states that Resident #75 told the Administrator that CNA #114 had been mean to her since she arrived and allegedly told her, when she asked for help, that if she could not learn to be patient she would be moved to the "bad hall" where there were more residents and it would take even longer to get help. The facility’s self-reported incident records showed that no SRI was created or submitted for this concern, even though the resident expressed being upset about how she was spoken to and treated. Personnel records showed CNA #114 had a history of corrective actions for poor customer service and unprofessional behavior, including being rude and negative toward residents and coworkers. An LPN stated she had to verbally educate CNA #114 about her tone of voice toward a resident in the dining room and reminded her that the resident’s home should be respected. Additional statements from the Unit Manager and another LPN described CNA #114 as rude, loud, and unprofessional toward residents and staff, including raising her voice in hallways and making disrespectful comments about a resident who refused a shower. The Administrator stated she spoke with Resident #75 by phone after hearing complaints from employees and determined the issue was poor customer service rather than abuse, so no SRI was completed. The DON stated CNA #114 had been restricted from working on one unit because of a prior issue involving a resident there and acknowledged that other staff had concerns about her rude and disrespectful behavior. The facility policy required suspected abuse to be reported immediately and investigated by reviewing records and interviewing relevant residents, family members, visitors, and other residents cared for by the accused employee.
Pureed Diet Prepared to Improper Texture
Penalty
Summary
The facility failed to prepare a pureed diet to the proper texture for eight residents identified as receiving a pureed diet, with a census of 90. During lunch tray service, the chipped beef and country gravy puree was observed being started, and a dietary staff member was seen pouring the pureed food into a metal container for service. The staff member did not taste the puree to check the texture, and larger pieces of chipped beef were observed in the food. When interviewed, the staff member stated, "I can go more but that's all the meat pieces will go down," indicating the food had not been fully pureed. The Dietary Manager then advised the staff member to puree the chipped beef and gravy longer, and a later observation showed a smoother texture.
Failure to Ensure Appropriate Antibiotic Use
Penalty
Summary
The facility failed to implement an antibiotic stewardship program that ensured appropriate antibiotic use for residents reviewed for antibiotic therapy. Surveyors reviewed records, interviewed staff, and reviewed the facility policy and found that antibiotics were continued or ordered for residents even when urine culture results did not support the selected antibiotic or when the documented symptoms and culture findings did not meet the facility’s infection criteria. For one resident with dementia, chronic kidney disease, and hypertension, a urine culture showed 20,000-25,000 CFU/ml of E. coli, and the resident’s only documented symptom was altered mental status. The infection screening evaluation did not indicate that urinary infection criteria were met, and the culture did not list the prescribed amoxicillin as a sensitive antibiotic. Staff confirmed the culture did not show greater than 100,000 bacteria and that amoxicillin was continued despite the culture findings. The DON stated the physician could order antibiotics even when criteria were not met, but the physician did not document the rationale for continuing the antibiotic. For another resident with diabetes, lymphedema, morbid obesity, and hypertension, a urine culture showed 26,000-30,000 CFU/ml of Proteus mirabilis after complaints of flank pain and burning with urination. The resident was afebrile and had acute dysuria, but the culture did not list cefdinir as a sensitive antibiotic. Staff confirmed the culture did not show greater than 100,000 bacteria and that cefdinir was not listed as sensitive. The medical director stated he chose to treat even though the culture did not meet criteria for infection. A third resident with severe cognitive impairment, cerebrovascular disease, COPD, and a history of urinary tract infections was placed on prophylactic Macrobid after hospice discontinued urine specimen collection and discussed low-dose prophylactic antibiotic use. The resident was always incontinent of urine and had an ileostomy. The DON agreed there was no valid indication for the Macrobid order, although the medical director later stated it was appropriate because of the resident’s history of urinary tract infections. The facility policy stated antibiotics were to be prescribed and administered under the guidance of the antibiotic stewardship program, which was intended to monitor antibiotic use in residents.
Physical restraint used for resident safety
Penalty
Summary
The facility failed to ensure Resident #69 was free from the use of a physical restraint. Resident #69 was admitted with diagnoses including senile degeneration of the brain, dementia with agitation, cerebrovascular disease, COPD, hypertension, bilateral hearing loss, and an above-knee right leg amputation. The resident’s MDS showed a BIMS of 00, dependence for toileting hygiene, transfers, rolling, and bed mobility, and that the resident was always incontinent of urine and had an ileostomy. The care plan identified the resident as a fall risk and noted that the resident sometimes lay at the opposite end of the bed and purposefully placed self on the floor. Interventions included a body pillow to the left side of the bed for safety, along with other fall-related measures. After an unwitnessed fall in which the resident was found sitting on the floor beside the bed, the IDT documented that the resident appeared to have slid out of bed and ordered the body pillow to the left side of the bed due to poor safety awareness. During later observations, the resident was seen lying in bed with the body pillow tightly tucked under the fitted sheet at the left edge of the bed and a fall mat on the floor nearby. A CNA confirmed the body pillow was in place to prevent the resident from scooting out of bed, and a medication aide stated the resident could remove the pillow if needed but then confirmed the resident could not remove it on command. The facility policy stated a device is considered a restraint if the resident cannot remove it in the same manner it was applied and if it restricts the resident’s typical ability to change position or place.
Psychotropic Medication Not Adequately Monitored
Penalty
Summary
The facility failed to ensure a resident receiving a psychotropic medication was adequately monitored for response to treatment. Resident #3 was admitted with diagnoses including Parkinson's induced psychosis with a history of visual and auditory hallucinations, paranoia, and Parkinson's disease with dyskinesia, and he had an order for pimavanserin 34 mg daily for hallucinations and delusions associated with Parkinson's disease psychosis. The resident's MDS documented moderately impaired cognition, dependence for multiple activities of daily living, incontinence, and no exhibited behaviors. Observations showed the resident sitting in a wheelchair with his eyes closed during lunch and later in his room with his eyes closed but verbally responsive, while also noted to have constant tongue and mouth movements. Review of psychiatric notes showed the resident had a history of hallucinations and paranoia, but nursing staff reported no observed signs or symptoms of psychosis and there had been no change in his movement disorder since before admission. Nursing progress notes documented decreased appetite, lethargy, confusion, and appearing sleepy, and the physician was notified of these changes. Weight records showed a loss from 226.4 pounds to 212 pounds over two months, and a nutritional note documented a 6.1 percent weight loss with a recommendation for Glucerna. Interviews with CNA and RN confirmed the resident slept off and on during the day, had no behaviors, and his involuntary movements and level of assistance had not changed since admission. The DON confirmed the facility had no behavior tracking in place to monitor targeted behaviors related to the antipsychotic medication, and the psychiatric NP stated staff should have been monitoring for targeted behaviors, including hallucinations.
Missed Physician Notification and Failure to Follow Insulin Orders
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and resident needs for three residents. For one resident with cerebral infarction, type 2 diabetes, hyperglycemia, hemiplegia/hemiparesis, depression, anxiety, and a history of falls, the record showed insulin orders were changed on 01/19/26 to Basaglar 35 units at bedtime and Humalog 5 units before meals and at bedtime, with a note in the physician progress record stating sliding scale insulin was also to be used. However, the medication administration record showed the resident received Basaglar and Humalog as ordered from 01/19/26 through 01/30/26, but no sliding scale insulin was administered. The DON stated the verbal order was documented only if the physician ordered it, and the MD stated that if it was in his progress notes, he expected the resident to be on sliding scale insulin. For another resident with Parkinson’s disease, vascular dementia, chronic heart failure, bilateral amputations, diabetes, malnutrition, and dysphagia, the care plan and physician orders required daily weights and notification of the physician for weight gains or losses of 3 pounds in one day or 5 pounds in one week. Review of the MAR and weights/vitals showed multiple daily and weekly weight changes that met the notification threshold, including repeated gains and losses across January, February, and March 2026. Progress notes did not document physician notification for these qualifying weight changes, and the only note found referenced a physician being informed on a date when the chart review did not identify a qualifying weight change. The DON confirmed the weights varied, that several daily weight changes of 3 or more pounds and weekly changes of 5 or more pounds occurred without documentation of physician notification, and the ADON confirmed many weight notifications were missed. For a third resident with sequelae of cerebral infarction, hemiplegia/hemiparesis, chronic respiratory failure with hypoxia, atrial fibrillation, atherosclerotic heart disease, and hypertension, the care plan called for monitoring and notifying the MD of cardiac distress and obtaining vital signs as indicated. The record showed a blood pressure of 201/92, followed by 188/73 after medication administration, then continued elevated readings of 177/99, 193/81, and 214/126 over the next several days. Although one note documented that the MD was notified on the first day and advised to give morning lisinopril and metoprolol and recheck in one hour, the MD later stated he was not aware the blood pressure continued to rise, and the regional nurse confirmed the facility was still looking for blood pressure notes left for the MD and had not received them. The facility policy stated hypertension should be reported to the physician and that several readings should be recorded when a resident has a hypertensive reading.
Failure to Monitor a Wandering Resident
Penalty
Summary
The facility failed to properly monitor a resident with a history of exit seeking and wandering. Resident #42 had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, restlessness and agitation, and insomnia, and the care plan identified the resident as at risk for elopement because of dementia, wandering, and being oblivious to safety needs. The care plan included interventions such as monitoring for increased exit-seeking behaviors, redirecting as needed, checking door alarms promptly, and ensuring exit doors were secured, but no elopement care plan updates were noted after 10/24/25. The resident's elopement and wandering risk assessment described unsafe wandering or elopement attempts with a score of 24, and no new assessment was completed on or after 03/06/26. On 03/06/26, the resident left the secured memory care unit alone while CNA #188 was not in sight and was providing care to another resident. The CNA did not promptly attend to the sounding door alarm or complete a head count. The facility incident log confirmed an incident on that date, and the resident's concern form stated the resident left the memory care unit without the CNA present. The facility investigation noted the resident was observed pushing on the memory care door until it opened and triggered the alarm. An observation on 03/09/26 showed the resident again trying to open the memory care unit door with the alarm sounding before being redirected to the room. The resident's record also lacked progress note documentation of the incident.
Improper BP Monitoring for Resident with Left Arm AV Fistula
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident with end stage renal disease, dependence on renal dialysis, and heart failure. The resident had a severely impaired BIMS score of 06 out of 15. The care plan identified an AV fistula in the left arm and included interventions to monitor the fistula and avoid blood pressure checks and lab draws in the left arm. Current orders also directed staff not to use the left arm for blood pressure, IV treatments, or blood draws because of the AV fistula. Review of the blood pressure log showed that the resident's blood pressure was obtained using the left arm 58 times between 01/02/2026 and 03/11/2026. During interview, LPNs stated that CNAs were given lists of residents needing vital signs, returned the lists after obtaining them, and did not normally indicate which arm was used. The LPN also verified that there were multiple incidents where the resident's blood pressure was checked using the left arm where the AV shunt was located, despite the order that blood pressures were not to be obtained with that arm.
Failure to Timely Review and Document Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations from the licensed pharmacist were reviewed, acknowledged, and addressed by the physician in a timely and medically appropriate manner for two residents. The report states that the facility’s policy required the pharmacist to provide written reports of irregularities and the attending physician to review and respond, with documentation in the resident’s medical record of the review and any actions taken. Surveyors found that this process was not followed consistently, and that nurses or the DON, rather than the physician, signed or annotated several pharmacy recommendations without physician documentation in the record. For one resident, who had Parkinson’s disease, vascular dementia, chronic heart failure, bilateral lower-extremity amputations, diabetes, malnutrition, and dysphagia, multiple pharmacy recommendations were issued regarding a zinc allergy discrepancy and epoetin alfa dosing. The record showed recommendations asking the physician to clarify whether zinc should be listed as an allergy and later to clarify a discrepancy between the facility order for epoetin alfa and the hospital AVS. Some recommendations were acknowledged by a nurse or marked with unclear physician initials, but the medical record contained no physician documentation clarifying the allergy issue or explaining the dosing discrepancy. The report also states that epoetin alfa was administered when the resident’s hemoglobin was above the stated hold parameter, and there was no documentation that the physician addressed the administration parameters or that staff were educated regarding the issue. For the second resident, who had chronic respiratory failure, vascular disease, heart failure, emphysema, liver disease, and muscle weakness, pharmacy recommendations addressed persistently low magnesium levels, a lidocaine patch order, Colace strength clarification, and later vitamin D and magnesium dosing concerns. The record showed that some recommendations were acknowledged by a nurse, the DON, or the physician, but two recommendations were not signed or acknowledged by the physician, and the medical record lacked evidence that the physician was informed or documented review of the issues. The DON confirmed that several recommendations involving low magnesium levels had no physician documentation, that the lidocaine order was never changed as documented on the pharmacy report, and that the Colace order was not changed for nine days after physician signature. The report also notes that several dates were illegible, making it impossible to prove timely review of the recommendations.
Unnecessary Medication Administration Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary medication when Epoetin Alfa Injection Solution was administered outside of the ordered parameters. Resident #2 was admitted with Parkinson’s disease, vascular dementia, chronic heart failure, right above-the-knee amputation, left below-the-knee amputation, diabetes, malnutrition, and dysphagia. The physician order dated 12/19/25 directed Epoetin Alfa 10,000 unit/mL, 1 mL subcutaneously every Friday for hemoglobin less than 10 and to hold if hemoglobin was greater than 10. Record review showed a hemoglobin of 10.0 on 12/31/25, yet the medication was administered on 01/02/26. A hemoglobin of 10.6 was documented on 01/21/26, and the MAR showed Epoetin Alfa was administered on 01/23/26. A hemoglobin of 11.0 was documented on 01/28/26, and the MAR showed the medication was administered again on 01/30/26. The pharmacy recommendation on 01/29/26 noted the medication had been given outside the parameters and asked that changes be evaluated and nursing educated on administration parameters. The DON confirmed the recommendation was related to staff administering the medication outside the parameters and confirmed the medication should have been held for hemoglobin results of 10.6 and 11.0.
Failure to Maintain Contact Precautions and Provide Proper Catheter Care
Penalty
Summary
The facility failed to maintain contact precautions for a resident with Clostridioides difficile infection and failed to provide proper catheter care for another resident. Resident #29 was admitted with diagnoses including C. difficile enterocolitis, MRSA infection, chronic pain, impaired lower extremities, dependence on staff for toileting and personal hygiene, and an indwelling catheter for urine elimination. The record showed positive C. difficile results, ongoing loose stools and diarrhea, and orders for fidaxomicin and a GI consult. Despite this, the resident was observed sitting in the dining room with other residents on multiple occasions, and the unit manager stated the resident was permitted to leave the room for meals because C. difficile is spread through feces-to-mouth contact. Staff interviews showed inconsistent understanding of the isolation status and equipment cleaning. A CNA stated Resident #29 had frequent incontinent episodes of liquid stool or diarrhea, that staff washed the resident before meals, and that she was not sure how often the Hoyer lift used for the resident was cleaned even though it was used on other residents. The administrator stated she was not sure whether isolation information had been relayed to the resident so the resident could decide whether to stay in the room, and this was not documented in the medical record. For Resident #66, the record showed diagnoses including cerebral infarction, hemiplegia, diabetes, morbid obesity, obstructive uropathy, retention of urine, and chronic kidney disease. The resident had an indwelling catheter inserted and an order for catheter care every shift, and later had urine cultures showing resistant E. coli and was placed on contact precautions for ESBL in the urine. During observation, a contracted phlebotomist entered the room wearing gloves but no gown while drawing blood from the resident, despite a contact precaution sign outside the room. During catheter care observation, a CNA cleansed only the catheter tube and did not cleanse the labia or urethral meatus, and another CNA poured the basin water down the hand sink in the resident’s room. The unit manager confirmed the phlebotomist should have worn a gown and that the catheter care was incomplete.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Circleville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pickaway Manor Care Center | 1.1 mi | ★★★★★ | 18 | 1 |
| Brown Memorial Home Inc | 1.4 mi | ★★★★★ | 8 | 0 |
| Logan Elm Health Care Center | 3.6 mi | ★★★★★ | 6 | 0 |
| Altercare Of Canal Winchester Post-acute Rc | 16.8 mi | ★★★★★ | 36 | 1 |
| Luxe Rehabilitation And Care Center | 16.8 mi | ★★★★★ | 3 | 0 |
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