Health inspection·April 17, 2025

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to monitor for mood and behaviors including target behaviors for a resident receiving antianxiety, antidepressants, and antipyshcotic medications. This affected one (Resident #44) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: Review of Resident #44's medical record revealed Resident #44 was admitted on [DATE]. Diagnoses included vascular dementia, anxiety disorder, restlessness and agitation, schizoaffective disorder - bipolar type, homicidal ideations, psychotic disorder with delusions, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 was severely cognitively impaired with no signs of psychosis or behaviors noted. Resident #44 received antipsychotic, antianxiety, and antidepressant medications. Review of the active orders for April 2025 revealed Resident #44 was receiving the following medications: Lorazepam oral concentrate two milligrams per milliliter with the dose of 0.25 milliliters every four hours as needed for anxiety or restlessness for 14 days starting 04/10/25. Risperidone 0.25 milligrams (mg) by mouth twice a day for vascular dementia and psychotic behaviors. Lexapro five mg by mouth one time a day for anxiety. Mirtazapine 15 mg at bedtime for depression. Ativan 0.5 mg by mouth twice a day for anxiety. Review of the care plan for Resident #44 revealed there should be monitoring of mood and behavior including target behaviors of hallucinations, agitation, incoherent speech, delusional thoughts, and disorganized thinking. Resident #44's medical record did not include Resident #44's mood and behavior were being monitored routinely. Interview 04/16/25 at 8:20 A.M. with the Director of Nursing (DON) confirmed they were not monitoring and tracking mood and behaviors including target behaviors for Resident #44 as indicated in Resident #44's plan of care. Review of the Medication Therapy policy dated April 2007 revealed a process to prescribe and monitor medications for residents that included monitoring for potential or suspected side effects of the medications prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365456 If continuation sheet Page 2 of 5 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 04/17/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interview, and policy review, the facility failed to honor the resident's food requests or preferences and ensure residents received food substitutions for foods they dislike. This affected two (Resident #51 and #72) of three residents reviewed for food preferences. The facility census was 82. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 05/06/22 with diagnoses including but not limited to Alzheimer's disease, dementia, congestive heart failure, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderate cognitive deficit. Review of Resident #51's diet order worksheet revealed Resident #51 disliked peas and carrots. Observation and interview on 04/15/25 from 12:40 P.M. to 12:46 P.M. of Resident #51's lunch plate revealed there was not a vegetable on her plate. Resident #51's lunch ticket on 04/15/25 at 12:40 P.M. revealed she dislikes carrots and peas. Dietician #444 stated if a vegetable being served was on the resident's dislikes list the facility would serve an alternative like a can of green beans. Dietician #444 stated the resident should receive a vegetable on the plate. Dietary Director #151 stated if the facility was serving a vegetable the resident doesn't like, they would get an alternative vegetable like a vegetable juice. Dietician #444 confirmed Resident #51 did not get a vegetable on her lunch tray. Resident #51 stated she would like green beans. 2. Review of the medical record for Resident #72 revealed an admission date of 01/09/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact. Review of Resident #72 diet order worksheet revealed Resident #72 disliked bacon, bananas, raisins, ham, corn, nuts, and seeds. Interview on 04/14/25 at 4:12 P.M. with Resident #72 stated she did not like the food at the facility and the staff do not pay attention to your likes and dislikes and they will serve you whatever food they have on hand. The staff were not taking food restrictions into account Observation and interview on 04/17/25 at 12:44 P.M. revealed Resident #72 was served corn on her lunch plate. Resident #72's lunch ticket revealed she dislikes corn. Certified Nursing Assistant (CNA) #269 verified Resident #72 received corn on her lunch plate and stated Resident #72 should not have received corn. Interview on 04/17/25 at 12:49 P.M. with Assistant Dietary Director #165 stated Resident #72 should not have received corn. Assistant Dietary Director #165 revealed the cook and aide serving at that time should be checking the ticket and meal. Review of the Therapeutic Diets policy dated 2001 revealed the diet will be determined in accordance with the resident's informed choices, preferences, and treatment goals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365456 If continuation sheet Page 3 of 5 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 04/17/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to ensure food was protected from contamination. This had the potential to affect all residents in the facility who receive food from the kitchen except for Resident #192 who received nothing by mouth. The facility census was 82. Findings include: Observation and interview on 04/15/25 at 11:50 A.M. revealed [NAME] #185 putting bread into the puree machine with her bare hands. [NAME] #185 was also crumpling the bread in the puree machine with her bare hands. [NAME] #185 stated she doesn't know if she needs to wear gloves. Dietician #444 verified [NAME] #185 should be wearing gloves when touching ready to eat food items. Interview on 04/15/25 at 11:51 A.M. with Assistant Dietary Director #165 stated the puree bread does not go through a cooking process and was served at room temperature. Observation and interview on 04/15/25 at 12:34 P.M. revealed [NAME] #185 was putting together a hamburger on a bun with her bare hands. [NAME] #185 confirmed she grabbed the burger buns with her bare hands to assemble the hamburger. Review of the Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy dated November 2022 revealed food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Contact between food and bare (ungloved) hands is prohibited. Gloves are worn when directly touching ready-to-eat foods. Review of the Food Preparation and Service policy dated 2001 revealed bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365456 If continuation sheet Page 4 of 5 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 04/17/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, staff and resident interview, and policy review, the facility failed to ensure the resident's hand sinks were working in the resident's room. This affected one (Resident #26) of 25 residents reviewed for physical environment. The facility census was 82. Findings include: Interview and observation on 04/14/25 at 4:24 P.M. with Resident #26 stated he did not have hot or cold water at his hand sink. Resident #26 stated he has not had water at his hand sink for three months and he can only get hot water if he turns on a valve underneath the hand sink. Observation of Resident #26's hand sink revealed there was no water coming from the hand sink. Observation and interview on 04/17/25 at 9:23 A.M. with Maintenance Director #209 confirmed Resident #26's hand sink was not returning hot or cold water. Maintenance Director #209 stated the stim was busted in the sink and he does not have any work orders for this issue. Interview on 04/17/25 at 9:30 A.M. with Certified Nursing Assistant (CNA) #286 confirmed Resident #26's hand sink was not working and it has been an issue for probably a month. CNA #286 stated she has told a nurse, and they put in the work orders. Review of the Maintenance Service policy dated December 2009 revealed the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365456 If continuation sheet Page 5 of 5