Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to update the pre-admission screening and resident
review (PASARR) for Residents. This affected three (#70, #72, and #80) of five residents reviewed for
PASARR. The facility census was 85.
Findings include:
1. Record review of Resident #70 revealed an admission date of 10/23/19, with diagnoses including:
congestive heart failure, atherosclerotic heart disease, cerebral infarction, dementia, chronic kidney
disease, major depressive disorder, bipolar disorder, anxiety disorder, schizophrenia, history of falling,
personal history of COVID 19, dysphagia following other cerebrovascular disease, muscle weakness,
abnormal posture, need for assistance with personal care, periapical abscess without sinus, disorder of
muscle, Parkinson's disease, seizures, anemia, generalized edema, osteoarthritis, idiopathic normal
pressure hydrocephalus, functional urinary incontinence, overactive bladder, hypertension, hypothyroidism,
burn of second degree of head face neck.
Review of the 08/17/22 annual Minimum Data Set (MDS) assessment revealed the resident was severely
cognitively impaired and required total dependence for transfer, locomotion on and off unit, toilet use, and
bathing. The resident requires extensive assistance for personal hygiene, eating, dressing, and bed
mobility.
Review of Resident #70 medical record on 09/20/22 at 10:27 A.M., revealed no current PASARR. The only
one in medical record was a hospital 30 day exemption from 10/23/19.
Interview with the Director of Nursing (DON) on 09/20/22 at 10:40 A.M., verified there was no current
PASARR available in the medical record.
2. Record review of Resident #72 revealed an admission date of 08/29/19, with diagnoses including:
dementia, severe protein-calorie malnutrition, adult failure to thrive, personal history of COVID-19, schizoid
disorder, anxiety disorder, gastrostomy status, difficulty in walking, muscle weakness, major depressive
disorder, constipation, generalized anxiety disorder, contact with exposure to other viral communicable
disease, dysphagia, hyperlipidimia, atherosclerotic heart disease of native coronary artery, vitamin D
deficiency, hypotension, and ventricular tachycardia.
Review of the 08/18/22 quarterly Minimum Data Set (MDS) assessment revealed the resident is severely
cognitively impaired and requires total dependence for bed mobility, transfer, locomotion on and off unit,
dressing, eating, toilet use, and bathing. The resident uses a wheelchair to aid in
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 11
Event ID:
365456
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
09/26/2022
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 0644
mobility and is frequently incontinent of bladder and always incontinent of bowel.
Level of Harm - Minimal harm
or potential for actual harm
Review of the Resident #72 medical record on 09/20/22 at 10:30 A.M., revealed there was no PASARR in
the record.
Residents Affected - Few
Interview with the Administrator on 09/20/22 at 12:15 P.M., verified there was no PASARR for Resident #72
in the medical record.
3. Record review for Resident #80 revealed this resident was admitted to the facility on [DATE], with
diagnoses including schizophrenia, bipolar disorder, phobic anxiety, major depressive disorder, and
insomnia.
Review of the admission Minimum Data Set (MDS) assessment, dated 09/04/22, revealed this resident had
intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13. This
resident was assessed to require extensive assistance from one staff member for toileting, bed mobility,
and transfers and supervision with setup help only for eating.
Review of the Preadmission Screening and Resident Review (PASARR) Identification Screen, dated
09/07/22, revealed the assessment was not accurately completed as the box for Schizophrenia had not
been marked.
Interview with Business Office Assistant #27 on 09/20/22 at 2:40 P.M., verified schizophrenia had not been
marked on the PASARR completed on 09/07/22.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365456
If continuation sheet
Page 2 of 11
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
09/26/2022
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, resident and staff interviews, the facility failed to ensure a physician ordered
treatment was clarified and obtained for a resident with a diabetic ulcer. This affected one (#286) of one
resident reviewed for non pressure ulcer. The facility census was 85.
Residents Affected - Few
Findings include:
Review of Resident #286's medical record revealed an admission date of 09/05/22, with diagnoses
including: osteomyelitis, cellulitis of the left lower limb, type two diabetes mellitus, morbid obesity, and
osteoarthritis.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had
intact cognition. The resident was assessed to require extensive assistance from one staff member for
toileting, supervision for bed mobility and transfers, and to be independent with setup help only for eating.
The resident was assessed to have a diabetic ulcer of the foot.
Review of the active care plans revealed there was not a care plan in place for the diabetic ulcer to the
resident's foot.
Review of the hospital Discharge summary, dated [DATE], revealed orders to continue treatments with
wound vacuum to the left lower extremity.
Review of facility admission Assessment, dated 09/05/22, revealed the presence of a diabetic ulcer to left
lateral foot with treatment orders in place.
Review of the physician's orders, revealed an order for wound care treatment to the diabetic ulcer of the
foot was not in place until 09/08/22, three days after the resident was admitted to the facility.
Review of the active physicians order, dated 09/08/22, revealed an order to cleanse the wound to the left
outer foot with wound cleanser and place a wound vacuum every Monday, Wednesday, and Friday.
Interview on 09/20/22 at 10:27 A.M., with Resident #286 revealed the resident had been admitted to the
facility on Monday 09/05/22 and had not had a wound care treatment completed to the diabetic foot ulcer
on his left foot until Friday 09/08/22.
Observation on 09/20/22 at 10:27 A.M., revealed Resident #286 had an ace wrap located on his left foot
and left lower leg which had drainage seeping through from the resident's diabetic foot ulcer.
Interview on 09/20/22 at 2:15 P.M., with the Director of Nursing (DON) verified there had been no treatment
orders in place for the diabetic foot ulcer on the left foot of Resident #286 from 09/05/22 through 09/08/22.
The DON verified the hospital Discharge summary, dated [DATE], contained instruction to continue
treatment with wound vacuum to the left lower extremity.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365456
If continuation sheet
Page 3 of 11
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
09/26/2022
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 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, resident and staff interview, the facility failed to assist the resident in making
appointments for hearing aides. This affected one (#38) of three residents reviewed for ancillary services.
The facility census was 85.
Residents Affected - Few
Findings include:
Review of Resident #38's medical record revealed an admission date of 05/20/10 and re-admission date of
06/18/14. Diagnoses for Resident #38 included: chronic obstructive pulmonary disease, contact with and
exposure to COVID-19, respiratory failure, morbid obesity, obstructive sleep apnea, type two diabetes
mellitus, symbolic dysfunction, heart failure, carcinoma of bronchus and lung, protein calorie malnutrition,
dysphagia phase, abnormal posture, staphylococcus, acute ischemic heart disease, gout, anxiety disorder,
pneumonia, unsteadiness on feet, encephalopathy, peritoneal abscess, muscle weakness, allergic rhinitis,
hypokalemia, diabetes mellitus type two with diabetic neuropathy, sepsis, abnormal weight loss, acute and
chronic respiratory failure with hypercapnia, hyperlipidemia, insomnia, osteoarthritis, major depressive
disorder, and hypertension.
Review of the 09/09/22 annual Minimum Data Set (MDS) assessment revealed the resident is cognitively
intact and requires total dependence for transfer, locomotion on unit, and bathing. The resident requires
extensive assistance for bed mobility, personal hygiene, and toilet use. The resident uses a wheelchair to
aid in mobility and is occasionally incontinent of bladder and frequently incontinent of bowel.
Interview on 09/19/22 at 3:13 P.M., with Resident #38 revealed the resident received a prescription for a
hearing aide in 2021 and never heard anything else about it.
Review of Resident #38 medical record on 09/20/22 revealed she had hearing aide consult on 08/24/21,
indicating she was medically evaluated and is considered a candidate for a hearing aide.
Review of the Progress Notes dated 04/14/22 at 8:00 A.M., revealed Resident #38 refused to go to
scheduled appointment times three. Risk and benefits explained and she voiced understanding. Medical
records notified of refusal and need to reschedule appointment.
Review of Resident #38 medical record revealed no follow up appointment was documented after the
04/14/22 appointment.
Review of the Progress Notes dated 09/21/22 at 10:00 A.M., revealed the resident has an audiology
appointment scheduled for hearing test on 12/16/22 at 2:00 P.M.
Interview with the Director of Nursing on 09/21/22 at 1:48 P.M., verified the facility just rescheduled
Resident #38 hearing aide appointment today after the surveyor brought it to their attention there was not a
follow up appointment scheduled.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365456
If continuation sheet
Page 4 of 11
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
09/26/2022
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on record review, resident and staff interviews, the facility failed to ensure the shower chair brakes
were locked for a resident who required assistance, resulting in a fall. This affected one (#52) of two
residents reviewed for falls. The facility census was 85.
Findings include:
Review of Resident #52s medical record revealed an admission date of 01/30/22, with diagnoses of: acute
respiratory failure, chronic respiratory failure, chronic pulmonary disease, morbid obesity, type two diabetes
mellitus with diabetic neuropathy, acute upper respiratory infection, history of COVID-19, cellulitis of limb,
dysphagia pharyngeal, cardiomyopathy, osteopenia and congestive heart failure.
Review of the 05/06/22 quarterly assessment revealed the Resident is moderately cognitively impaired and
required extensive assistance for toilet use and limited assistance for personal hygiene, dressing, bed
mobility and transfer. The resident required physical help in bathing and one person physical assist. The
Resident uses a walker and wheelchair to aid in mobility and is occasionally incontinent of bladder and
always continent of bowel. Balance during transition was labeled as not steady but able to stabilize without
staff assistance.
Review of a fall investigation dated 05/25/22 revealed Resident #52 had a fall in the shower and the shower
chair wheels were not locked and the resident fell from the chair and suffered a compression fracture.
Interview with Resident #52 on 09/19/22 at 2:07 P.M., revealed he had a fall in the shower a few months
ago. Resident #52 stated he was not really hurt just felt some discomfort.
Interview with the Director of Nursing (DON) on 09/21/22 at 10:49 A.M., verified the shower chair brakes
were not locked, when Resident #52 had a fall on 05/25/22 and the only corrective action was the staff
member was written up.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365456
If continuation sheet
Page 5 of 11
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
09/26/2022
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, staff interviews, and record reviews, the facility failed to ensure medication was available and
administered as ordered by the physician. This affected one (#42) of five residents reviewed for
unnecessary medications. The facility census was 85.
Findings include:
Record review for Resident #42 revealed this resident was admitted to the facility on [DATE] and had
diagnoses including hypertension, schizoid disorder, unspecified dementia with behavioral disturbances,
anxiety disorder, mood disorder, and unspecified psychosis.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/22/22, revealed the resident had
moderately impaired cognition. The resident was assessed to require extensive assistance from one staff
member for bed mobility, transfers, and toileting, and supervision for eating.
Review of the physician's order, dated 07/25/22, revealed an order to administer 7.5 milligram (mg) tablet
and one mg of Olanzapine (an antipsychotic medication) once a day for schizoid disorder. There was a
pharmacy warning indicating Dosage Check present.
Review of the Order Audit Report for the physician ordered of Olanzapine, one mg tablet revealed the
medication had been on order from the pharmacy since 07/25/22 and no deliveries of the medication had
been sent.
Review of the Medication Administration Records for July, August and September 2022, revealed the
resident was only receiving Olanzapine 7.5 mg daily.
Review of the progress notes July, August and September 2022, revealed the resident was not displaying
any increase in behaviors.
Observation on 09/21/22 at 4:00 P.M., revealed the medication Olanzapine one mg tablet was not available
for administration on the 400- hall medication cart.
Interview on 09/21/22 at 4:00 P.M., with Licensed Practical Nurse (LPN) #145 verified the medication
Olanzapine one mg tablets were not available for administration to Resident #42.
Observation on 09/21/22 at 4:50 P.M., revealed Olanzapine one mg tablets were not available in the facility
Omnicell (emergency medication box) to be pulled for administration to Resident #42. Olanzapine was only
available for administration in the dosage amount of 2.5 mg or 5 mg from the Omnicell.
Interview on 09/21/22 at 4:50 P.M., with Registered Nurse (RN) #92 verified Olanzapine one mg tablets
were not available for administration to Resident #42 from the facility Omnicell.
Interview with the Director of Nursing (DON) on 09/22/22 at 10:05 A.M., verified the facility had no record to
indicate the medication Olanzapine one mg tablet had been available in the facility to administer to
Resident #42 since 07/25/22.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365456
If continuation sheet
Page 6 of 11
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
09/26/2022
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record reviews, observations, and staff interviews, the facility failed to ensure the
medication error rate was less than five percent, as evidence by six medication errors out of 26
opportunities observed, resulting in 23.07 % (percent) medication error rate. This affected two (#57 and
#77) of three residents observed for medication administration. The facility census was 85.
Residents Affected - Few
Findings include:
1. Review of Resident #77's medical record revealed an admission date of 04/03/15, with diagnoses
including: chronic congestive heart failure, venous insufficiency, conjunctivitis, atrial fibrillation, and history
of COVID-19.
Review of a Physician Order for Resident #77 dated 02/08/21, revealed an order for Artificial Tears Solution
1.4 % (Polyvinyl Alcohol), instill two drops in both eyes three times a day for dry eyes.
Observation on 09/21/22 at 7:45 A.M. , of the medication administration pass with Certified Medicine Aide
(CMA) #1 revealed Resident #77 received medications including: amiodarone, colace, eliquis, lasix,
gabapentin, losartan, metoprolol, multi-vitamin, and prilosec. Resident #77 was not observed to receive
artificial tears eye drops. CMA #1 verified at the time of the administration, this was all of Resident #77
medications and she had not given any medicine earlier.
Interview on 09/21/22 at 8:07 A.M., with CMA #1 verified Resident #77 did not receive his artificial tears
eye drops with morning during the medication pass as ordered.
2. Review of Resident #57's medical record revealed an admission date of 05/24/22, with diagnoses
including: multiple sclerosis, schizophrenia, hypertension, anxiety disorder, major depressive disorder,
urinary tract infection, constipation, and anemia.
Review of the Physician Order for 09/01/22 to 09/30/22 revealed medications including: aripiprazole (abilify)
tablet five milligrams (mgs) give one tablet by mouth in the morning for schizoaffective; glycoLax powder
(Miralax) give 17 gram by mouth one time a day for constipation; Leflunomide tablet 20 mgs give one tablet
by mouth in the morning for Rheumatoid Arthritis; Venlafaxine (Effexor) Tablet 100 mgs give two tablets by
mouth one time a day for depression, and stress plus zinc tablet give one tablet by mouth in the morning for
supplement.
Observation on 09/21/22 at 8:25 A.M., revealed CMA #90 passing medications to Resident #57 including:
baclofen, biotin, eliquis, fluconazole, oxybutyn, senna, thiamine, vitamin E, and metoprolol. Resident #57
was not observed to receive her abilify, Miralax, Leflunomide, Effexor, and stress tab plus zinc. CMA #90
verified at the time of the administration this was all of Resident #57 medications and she did not give any
medicine earlier.
Interview with CMA #90 on 09/21/22 at 9:10 A.M., verified Resident #57 did not receive her abilify, Miralax,
Leflunomide, Effexor, and stress tab plus zinc as ordered.
This deficiency substantiates Complaint Numbers OH00135754 and OH00135753.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365456
If continuation sheet
Page 7 of 11
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
09/26/2022
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interviews, record review, and review of facility policy, the facility failed to ensure accurate
documentation of medication administration. This affected one (#42) of five residents whose medications
were reviewed during the annual survey. The facility census was 85.
Findings include:
Record review for Resident #42 revealed this resident was admitted to the facility on [DATE] and had
diagnoses including hypertension, schizoid disorder, unspecified dementia with behavioral disturbances,
anxiety disorder, mood disorder, and unspecified psychosis.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/22/22, revealed the resident had
moderately impaired cognition. The resident was assessed to require extensive assistance from one staff
member for bed mobility, transfers, and toileting, and supervision for eating.
Review of the physician's order, dated 07/25/22, revealed an order to administer 7.5 milligram (mg) tablet
and one mg of Olanzapine (an antipsychotic medication) once a day for schizoid disorder. There was a
pharmacy warning indicating Dosage Check present.
Review of the Order Audit Report for the physician ordered of Olanzapine, one mg tablet revealed the
medication had been on order from the pharmacy since 07/25/22 and no deliveries of the medication had
been sent.
Review of the Medication Administration Record (MAR), dated 07/26/22 through 09/22/22, revealed the
medication Olanzapine one mg tablet had been documented as being administered every day as ordered
by the physician.
Observation on 09/21/22 at 4:00 P.M., revealed the medication Olanzapine one mg tablet was not available
for administration on the 400- hall medication cart.
Interview on 09/21/22 at 4:00 P.M., with Licensed Practical Nurse (LPN) #145 verified the medication
Olanzapine one mg tablets were not available for administration to Resident #42.
Observation on 09/21/22 at 4:50 P.M., revealed Olanzapine one mg tablets were not available in the facility
Omnicell (emergency medication box) to be pulled for administration to Resident #42. Olanzapine was only
available for administration in the dosage amount of 2.5 mg or 5 mg from the Omnicell.
Interview on 09/21/22 at 4:50 P.M., with Registered Nurse (RN) #92 verified Olanzapine one mg tablets
were not available for administration to Resident #42 from the facility Omnicell.
Interview with the Director of Nursing (DON) on 09/22/22 at 10:05 A.M., verified the facility had no record to
indicate the medication Olanzapine one mg tablet had been available in the facility to administer to
Resident #42 since 07/25/22. The DON verified the MAR contained documentation Olanzapine one mg
tablet had been administered every day from 07/26/22 through 09/22/22 as ordered by the physician
despite the facility not having the medication available for administration.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365456
If continuation sheet
Page 8 of 11
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
09/26/2022
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Review of the policy titled Documentation of Medication Administration, revised 04/2007, revealed a Nurse
or Certified Medication Aide shall document all medications administered to each resident on the resident's
MAR. The administration of medication must be documented immediately after it is given. Documentation
must include, as a minimum, the reason why a medication was not administered.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365456
If continuation sheet
Page 9 of 11
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
09/26/2022
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, medical record review, review of physician note, staff interviews, and review of
facility policy, the facility failed to ensure staff were wearing appropriate personal protective equipment
(PPE) when entering a COVID-19 positive Resident #1's room. The facility also failed to ensure appropriate
cleaning of a glucometer after blood glucose testing was performed. This had the potential to affect the four
residents (#13, #33, #59, and #67) who resided on the 400 hall and had blood glucose testing performed.
The facility census was 85.
Residents Affected - Some
Findings include:
1. Review of Resident #1 medical record revealed an admission date of 05/31/22, with diagnoses including:
chronic obstructive pulmonary disease, anemia, multiple sclerosis, and COVID-19.
Review of Resident #1 medical record revealed a Physician order dated 09/15/22 for Droplet isolation
precautions related to COVID positive every day and night shift until 09/23/22.
Observation on 09/21/22 at 8:35 A.M., revealed State Tested Nurse Aide (STNA) #73 going into Resident
#1's room. STNA #73 donned a gown and gloves and was wearing a pair of goggles and a surgical
facemask. STNA #73 walked into Resident #1's room and grabbed the tray and walked out of the room with
her gown and gloves still on and grabbed the door handle of the dining cart which was approximately six
feet outside the room. STNA #73 placed the tray in the cart and proceeded to go to the doorway and
remove her gloves and gown. STNA #73 was observed not to wear a N95 in the room or remove her
surgical mask or clean her eyewear.
Interview on 09/21/22 at 8:35 A.M., with STNA #73 revealed she has a doctor note to not wear a N-95
mask. STNA #73 verified she collected the meal tray from Resident #1 and wore her gloves, gown, out into
the hallway and touched the dining cart with her gloved hands. STNA #73 verified she did not change her
surgical mask after leaving Resident #1 room. STNA #73 was touching her surgical mask with her hands
during the interview. STNA #73 again stated she has a doctor's note stating she can wear a surgical mask.
Review of a document from Physician #2 dated 12/27/21, revealed to please allow STNA #73 to wear a
regular surgical grade mask with a full face shield or alternatively a powered air purifying respirator (PAPR)
as opposed to N95, while caring for patients who are not COVID positive. Physician #2 stated he
recommend an N95 and full face mask while caring for patients who are COVID positive during the normal
isolation period.
Interview on 09/21/22 at 3:15 P.M., with the Administrator revealed they do not have a policy for when staff
members who can only wear surgical masks providing care during COVID outbreak. So the facility did
training on 09/21/22 and those staff should not enter isolation rooms.
2. Observation on 09/21/22 at 3:50 P.M., revealed Licensed Practical Nurse (LPN) #145 performed blood
glucose monitoring for Resident #67. LPN #145 then took the glucometer used for the testing back to the
nurses station and cleansed it using Lysol brand wipes from a container located on the 400 hall medication
cart. LPN #145 then placed the glucometer into the medication cart.
Interview on 09/21/22 at 4:00 P.M., with LPN #145 verified she had used Lysol brand wipes to clean the
glucometer after blood glucose testing.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365456
If continuation sheet
Page 10 of 11
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
09/26/2022
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Interview on 09/21/22 at 4:20 P.M., with Corporate Nurse #200 revealed bleach wipes or Sani-Wipes were
to be used to clean glucometers after blood glucose testing was performed and Lysol brand wipes were not
to be used. Corporate Nurse #200 identified four residents (#13, #33, #59, and #67) who resided on the
400 hall and had blood glucose testing performed.
Review of the policy titled Blood Sampling - Capillary (Finger Sticks), revised 09/2014, revealed clean and
disinfect reusable equipment after each use following manufacturer's instructions.
Event ID:
Facility ID:
365456
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the September 26, 2022 survey of CIRCLEVILLE POST-ACUTE?
This was a inspection survey of CIRCLEVILLE POST-ACUTE on September 26, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CIRCLEVILLE POST-ACUTE on September 26, 2022?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Coordinate assessments with the pre-admission screening and resident review program; and referring for services as neede..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.