Health inspection·January 2, 2020

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, the facility failed to ensure residents received proper treatment and care for foot health when they failed to timely transcribe and implement treatment and medication orders for one resident (#56) of three reviewed for skin conditions. The facility census was 68. Residents Affected - Few Findings include: Medical record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, and foot ulcer. Interview with Resident #56 on 12/30/19 at 11:05 A.M. revealed she seen the foot doctor this morning. Review of the medical record on 01/02/2020 at 11:05 A.M. revealed a consult order dated 12/30/19 from the foot doctor with orders to apply triple antibiotic ointment and a band aid to the left great toe and change every day for ten days. The second order stated to give doxycycline (an antibiotic)100 milligrams (mg) one tab by mouth, every day for ten days. There was no evidence a physician order had been completed in the medical record or the electronic record for the triple antibiotic ointment and a band aid to the left great toe, or for the Doxycycline ordered. Interview with the Director of Nursing (DON) on 01/02/2020 at 1:34 P.M. verified there was no orders in the medical record for the medication and treatment for Resident #56 for when she saw the foot doctor on 12/30/19. The DON verified Resident #56 was not getting the treatments and medication since the order was not put into the electronic physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365456 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circleville Post-Acute 1155 Atwater Avenue Circleville, OH 43113 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to provide a physician ordered splint for a resident with contractures. This affected one resident (#57) of four reviewed for contractures with splints. The facility census was 68. Findings include: Review of the medical record for Resident #57 revealed an admission date of 06/05/15 with diagnoses including hemiplegia and hemiparesis following cerebral infarction left non dominant side, contracture of left hand, and mood disorder. Review of significant change minimum data set assessment dated [DATE] revealed Resident #57 had no cognitive deficits, and had impairment in range of motion to one side upper and lower extremities. Review of physician orders for Resident #57 dated December 2019 revealed an order for a left hand resting splint to be worn two hours on, then two hours off daily, as tolerated, and may remove for activities of daily living. Review of the care plan revealed Resident #57 had self care deficits related to weakness, cerebral vascular accident with hemiplegia and hemiparesis and included intervention of the left hand splint, as ordered. Review of the medical record including behavior monitoring revealed no documentation that Resident #57 had refused to wear left hand splint on 12/30/19, 12/31/19, or 01/02/2020. Review of the treatment administration record (TAR) dated 01/02/2020 revealed the nurse documented Resident #57 was wearing left hand splint on 01/02/19. Observations of Resident #57 on 12/30/19 at 12:34 P.M. and 4:29 P.M., on 12/31/19 at 11:50 A.M. and on 01/02/19 at 9:10 A.M., at 1:14 P.M., and at 1:45 P.M. revealed the resident did not have a splint in place to his left hand. Interview on 01/02/19 at 1:14 P.M. with State Tested Nursing Assistant (STNA) #155 revealed she was unaware Resident #57 was to have a left hand splint on. Interview on 01/02/19 at 1:41 P.M. with Resident #57 and his mother who was at his bedside both revealed he had not had a splint on his left hand ever. Resident #57 stated he would wear one because his overall goal was to be able to open up his left hand. Interview on 01/02/19 at 1:45 P.M. with the Director of Nursing (DON) verified Resident #57 had orders for a left hand splint to be on two hours, off two hours, and he did not have left hand splint on, even though the nurse had documented one was in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365456 If continuation sheet Page 3 of 3