Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
Based on observation, staff interview, review of the facility's policy and record review, the facility failed to
timely assess and monitor Resident #51's bruises on her bilateral hands. This affected one (Resident #51)
of one resident reviewed for non-pressure related skin wounds. The facility identified 15 residents with
non-pressure related skin wounds. The facility census was 76.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #51 revealed an admission date of 09/02/21. Diagnoses included
non-displaced fracture of the left hip, unspecified fracture of left pubis and sacrum, dementia with
behavioral disturbance, and chronic pain.
Review of the five-day Medicare Minimum Data Set (MDS) assessment, dated 09/28/21, revealed Resident
#51 was cognitively impaired, required two person physical assistance with bed mobility, transfers and
mobility. The resident was totally dependent on staff for bathing. There were no pressure or non pressure
related skin impairments noted.
Review of the plan of care, dated 10/06/21, revealed Resident #51 was at risk for impaired skin integrity
related to immobility and incontinence. The plan of care revealed no update related to the bruising of
Resident #51's bilateral hands.
Review of the signed physician orders and telephone orders, dated 11/2021, revealed there was no order to
asses or monitor the bruising to Resident #51 bilateral hands.
Review of the nursing progress notes, dated 10/25/21 through 11/03/21, revealed there was no
documentation related to the bruises on Resident #51's bilateral hands.
Observations on 11/01/21 at 12:10 P.M., on 11/02/21 at 3:58 P.M., and on 11/03/21 at 10:02 A.M. of
Resident #51 revealed the resident was seated in a geri-chair at the dining table in the main sitting area.
The top of Resident #51's left hand was deep blue, purple and was approximately four centimeters (cm) by
four cm in diameter. There were two small scabbed areas from skin tears. The right hand had scattered
bruises noted.
An interview with State Tested Nursing Assistant (STNA) #279 on 11/03/21 at 6:54 A.M. revealed the STNA
reported the bruises on Resident #51's hands to the nurse. However, STNA #279 could not remember
which nurse she reported the bruises to. STNA #279 said the bruises had been there for a week and was
not sure how it happened. STNA #279 said the resident's skin was examined with bathing and any skin
issues were reported to the nurse.
(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 7
Event ID:
365556
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
365556
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pickaway Manor Care Center
391 Clark Drive
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
An interview with Registered Nurse (RN) #232 on 11/03/21 at 3:20 P.M. confirmed Resident #51 had a
significant sized bruise to the top of her left hand with two small scabbed areas and scattered bruises to the
right hand. RN #232 said all bruises were monitored and documented on the Treatment Administration
Record and would be care planned.
An interview with the Director of Nursing (DON) #280 on 11/04/21 at 8:31 A.M. revealed the DON was not
aware of the bruises to Resident #51's hands. The DON confirmed there was no physician order to monitor,
no documentation, no assessment or plan of care update related to the bruises on Resident #51's bilateral
hands.
Review of the facility's policy titled Skin Conditions dated 08/02/21 revealed any hematoma/bruise would be
documented at time of discovery and the physician would be notified of any negative findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365556
If continuation sheet
Page 2 of 7
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
365556
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pickaway Manor Care Center
391 Clark Drive
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 medical record review, resident interview, and staff interview, the facility failed to ensure a
resident received treatment and assistive devices to maintain hearing abilities. This affected one (Resident
#32) of three residents reviewed for vision/hearing. The facility identified five residents with impaired
hearing. The facility census was 76.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #32 revealed an admission date of 02/06/13. Review of the
quarterly Minimum Data Set (MDS) assessment, dated 10/15/21, revealed Resident #32 had moderate
cognitive impairment, had minimal difficulty hearing, and did not wear hearing aides.
Review of the physician's order, dated 02/11/21, revealed Resident #32 had an order for hearing aide care
including insert in the morning and take out in evening.
Review of the social service progress notes revealed on 08/27/21, it was documented Resident #32 had
lost hearing aides and an appointment was being made to get a new set. On 10/20/21 at 9:27 A.M., it was
documented Resident #32 had hearing aides but had lost them and the resident was waiting to go to the
Veteran's Affairs (VA) office to get a new exam and aides. As of 11/03/21, there was no evidence in the
medical record that Resident #32 had an hearing aide appointment set up or had been evaluated for new
hearing aides.
Interview with Resident #32 on 11/01/21 at 3:29 P.M. revealed the resident to be very hard of hearing. The
resident stated he had lost his hearing aides a few months ago during a room change. He stated the facility
was supposed to be replacing them.
Interview with Social Service Coordinator (SSC) #292 on 11/03/21 at 2:00 P.M. verified Resident #32's
hearing aides had been missing since April 2021. SSC #292 stated Resident #32 had not had a hearing
exam since 2016 so the VA wanted to see him for a hearing exam prior to getting new hearing aides. SSC
#292 verified Resident #32 did not have an appointment and had not been seen for new hearing aides as
of 11/03/21.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365556
If continuation sheet
Page 3 of 7
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
365556
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pickaway Manor Care Center
391 Clark Drive
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 0801
Level of Harm - Minimal harm
or potential for actual harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on staff interviews and record review, the facility failed to have a qualified dietary service manager.
This had the potential to affect all 76 residents receiving food from the kitchen. The facility census was 76.
Residents Affected - Many
Findings include:
Review of the facility's staff roster revealed the facility did not employee a full-time registered dietician.
Review of the personnel file for Dining Services Manager (DSM) #238 revealed an absence of required
degrees or certifications necessary for employment in the held position.
Interview with Human Resource Assistant (HRA) #333 on 11/04/21 at 1:55 P.M. verified DSM #238 had not
submitted any proof of certifications or degrees required to be employed as the facilities dietary service
manager.
Interview with the Administrator on 11/04/21 at 2:05 P.M. verified the facility had not been provided copies
of certification or a degree by DSM #238.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365556
If continuation sheet
Page 4 of 7
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
365556
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pickaway Manor Care Center
391 Clark Drive
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on resident interviews, staff interviews, and review of the food committee meeting minutes, the
facility failed to ensure food was served to the residents at the proper temperatures and resident
preferences and failed to address expressed concerns by the residents in the food committee meetings.
This had the potential to affect all 76 residents who receive food from the kitchen. The facility census was
76.
Residents Affected - Many
Findings include:
Review of the food committee meeting minutes revealed the following: On 06/23/21, the food committee
meeting minutes reflected resident food preferences were not honored and the facility staff did not listen to
the residents when they voiced food dislikes. On 07/21/21, the food committee meeting minutes reflected
the residents again complained their food preferences were not honored. On 08/31/21, the food committee
meeting minutes reflected the residents' food was served cold, mostly at breakfast. On 09/30/21, the food
committee meeting minutes reflected the residents complained of cold food due to the use of paper plates
and due to short dietary staffing. On 10/29/21, the food committee meeting minutes reflected the chicken
was served burnt and the pieces were too large to eat.
A sign posted in the kitchen dated 10/29/21 stated to make sure everyone received a hot dog, bun, and
chili, and to serve gravy to the residents who had difficulty chewing, make sure potatoes were steamed well
before making potato soup as there were a lot of complaints about potatoes not being done. The notice was
signed by Dietary Manager #238.
Interview with Resident #272 on 11/01/21 at 11:44 A.M. revealed the food served was not very good and
sometimes the hot foods were cool.
Interview with Resident #23 on 11/01/21 at 4:15 P.M. revealed the food does not taste good, and the food
was not not fully cooked.
Interview with Resident #33 on 11/01/21 at 4:34 P.M. revealed the food on his meal tray was served cold,
and he could not specify a certain meal just in general.
Interview with Resident #16 on 11/02/21 at 8:22 A.M. revealed the facility's food use to be good, but now
the food was served cold. She stated for one meal, all she got was a meat sandwich and a cup of water.
Resident #16 stated she did not get enough food to fill her up, so her son brings snacks in for her because
of the food. She stated at yesterday's (11/01/21) lunch meal her chicken and the cheese broccoli were too
hard to chew. Resident #16 stated the food was hard and not fully cooked.
Interview with Stated Tested Nursing Assistant (STNA) #333 on 11/03/21 at 3:36 P.M. revealed she
received resident complaints of cold food when the facility used paper plates, and the food just did not stay
hot.
Interview with Registered Dietitian Nutritionist (RDN) on 11/03/21 at 11:17 A.M. confirmed the residents
have voiced food complaints and she was not aware of the posted sign until asked about it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365556
If continuation sheet
Page 5 of 7
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
365556
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pickaway Manor Care Center
391 Clark Drive
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
observation, resident and staff interview, record review, and policy review, the facility failed to honor a
resident's food preferences. This affected one (Resident #16) of one resident reviewed for choices. The
facility census was 76.
Findings include:
Review of Resident #16's medical record revealed she was admitted on [DATE]. Diagnoses included
chronic obstructive pulmonary diseases, visual loss, glaucoma, macular degeneration, emphysema, major
depressive disorder, and gastro-esophageal reflux disease.
Review of Resident #16's annual Minimum Data Set (MDS) assessment, dated 05/11/21 revealed Resident
#16's vision was severely impaired, and her cognition was intact. Resident #16 required supervision of staff
with set up help to eat.
Review of Resident #16's plan of care, dated 05/21/21, revealed she had vision loss and staff were to orient
her to her dining plate after it was set up.
Review of Resident #16's documented food preferences revealed she requested two slices of bacon, a
banana, three/fourths cup cold cereal, scrambled eggs, sugar packet, white bread, four ounces of apple
juice, a cup of decaffeinated coffee, a cup of milk and a cup of water on her meal tray. Resident #16 disliked
the following: biscuits, wheat bread, Cheerios, cream of wheat, fried eggs, cranberry muffins, oatmeal,
pineapple, runny eggs, sausage, sausage gravy and biscuits, toast , and yogurt.
Interview with Resident #16 on 11/02/21 at 8:03 A.M. revealed she told staff she was allergic to yogurt, yet
she still received it on her tray. Resident #16 stated they did not pay attention to her likes and dislikes they
send. Resident #16 stated the younger State Tested Nursing Assistants (STNA) did not tell her the location
of her food.
Observation of Resident #16's meal tray on 11/02/21 at 8:31 A.M. revealed she received pancakes, cold
cereal , orange juice and milk. She did not receive eggs or a cup of water on her tray. Her water pitcher in
her room was empty. Resident #16 stated she was not told where her food was on the tray.
Observation on 11/04/21 at 8:30 A.M. revealed STNA #340 delivered Resident #16's meal tray. STNA #340
did not tell Resident #16 where her food was on the plate. Resident #16 received cooked cereal, no milk,
scrambled eggs, two slices of toast, and cranberry juice. Resident #16 did not receive water (her water
pitcher in her room was empty). Resident #16 told STNA #340 she did not like cranberry juice and STNA
#340 told Resident #16 she needed to let the kitchen know. Resident #16 confirmed she did not receive
water, that she did not like cooked cereal or cranberry juice.
Observation of Resident #16's water pitcher on 11/04/21 at 9:29 A.M. was still empty.
Interview with STNA #333 on 11/04/21 at 9:19 A.M. revealed she did not work the hall Resident #16 lived
on. STNA #333 was not aware she needed to tell Resident #16 where her food was on her tray.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365556
If continuation sheet
Page 6 of 7
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
365556
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pickaway Manor Care Center
391 Clark Drive
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
record review, staff interview, and policy review, the facility failed to ensure a resident's medical record was
complete and accurately documented. This affected one (Resident #58) of 24 resident's record reviewed.
The facility census was 76.
Findings include:
Review of the medical record for Resident #58 revealed an admission date of 12/01/17. Diagnoses included
schizophrenia, bipolar disorder, epilepsy, and morbid obesity. Review of the Minimum Data Set (MDS)
assessment dated [DATE] revealed Resident #58 had moderately impaired cognition and required
supervision for walking.
Review of the progress notes revealed Resident #58's fall on 10/29/21 was not documented in the medical
record.
Review of a fall investigation report revealed on 10/29/21 at 7:00 P.M., Resident #58 was found sitting on
the floor. Resident #58 was putting on her pajamas and went to sit on the seated walker. The walker slid out
from under Resident #58 as she forgot to lock the brakes. State Tested Nursing Aide (STNA) #234
responded to the call light and found Resident #58. The nurses on duty were Registered Nurse (RN) #221
and Licensed Practical Nurse (LPN) #293 (who was on her last day of orientation/training). Resident #58
was assessed and vital signs were checked. No injuries were noted and the resident had no complaints of
pain. The fall investigation report was dated 11/01/21 then changed to 10/29/21. The incident report was
dated 11/01/21. The pain assessment was dated 10/29/21. The incident report documented that the
physician and family were notified on 10/29/21.
Interview with LPN #293 on 11/03/21 at 10:20 A.M. revealed she was in orientation/training with RN #221
on 10/29/21 when Resident #58 fell. LPN #293 stated the fall did happen right at shift change. LPN #293
went and assessed Resident #58 and checked her vital signs. LPN #293 stated she completed the required
paper work for the fall which included an incident report, fall investigation report, and pain assessment on
11/01/21, not on 10/29/21 when the fall happened. LPN #293 confirmed the physician and family were not
notified on 10/29/21 and that she had put the wrong date on the incident report. She stated they were
notified on 11/01/21.
Interview with RN #221 on 11/03/21 at 11:39 A.M. revealed she was on duty when Resident #58 fell. RN
#221 verified she did not complete any of the required paper work for a fall which included a nurses's note,
an incident report, and a fall investigation form.
Interview with the Director of Nursing on 11/03/21 at 10:55 A.M. revealed she was notified on 10/30/21 that
the required paperwork had not been completed for Resident #58's fall. She confirmed the paperwork was
completed on 11/01/21 by LPN #293 but should have been completed at the time of the fall. She verified
falls should be documented in the nurse's notes.
Review of the facility's policy titled Accident and Incident Reporting Protocol revised 04/23/19 revealed an
incident report shall be completed on all incidents and accidents that occur in the center. The nursing staff
will begin an investigation immediately following the incident or accident. All incidents and accidents will be
followed up for 24 hours post incident with a nursing progress note.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365556
If continuation sheet
Page 7 of 7
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Back to topCitations
6 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.
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.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the November 8, 2021 survey of PICKAWAY MANOR CARE CENTER?
This was a inspection survey of PICKAWAY MANOR CARE CENTER on November 8, 2021. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PICKAWAY MANOR CARE CENTER on November 8, 2021?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
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.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.