Health inspection·May 8, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to notify the physician when a resident experienced a significant weight change. This affected one (Resident #76) out of three residents reviewed for nutrition. The census was 75. Findings include: Review of the medical record for Resident #76 revealed Resident #76 was admitted to the facility on [DATE]. Resident #76's diagnoses included but were not limited to unspecified severe protein-calorie malnutrition, chronic kidney disease, pulmonary hypertension, cardiomegaly, congestive heart failure, atrial fibrillation, edema, cardiomyopathy, and hypertension. Review of Resident #76's Minimum Data Set (MDS) assessment, dated 02/03/24, revealed she was cognitively intact. Review of Resident #76's weights revealed she had the following weights recorded: 135 pounds on 01/29/24 , 147.2 pounds on 02/05/24, and 157 pounds on 02/12/24. Review of Resident #76's nutritional notes and documentation, dated 01/29/24 to 02/16/24, revealed no evidence to support the physician was notified of Resident #76's significant weight gain of 12.2 pounds (nine percent [%]) from 01/29/24 to 02/05/24 and significant weight gain of 22 pounds (16.3%) from 01/29/24 to 02/12/24. Interview with Corporate Dietitian #148 on 05/08/24 at 11:25 A.M. and 11:57 A.M. confirmed there was no evidence to support the physician was notified of Resident #76's significant weight gains between 01/29/24 to 02/12/24. Review of the facility Change in Condition Notification policy, dated 08/09/23, revealed the nurse will notify the resident, the resident's physician/practitioner, and the resident's designated representative when there is a significant change in the resident's physical, mental, or psychosocial status or a need to alter the resident's medical treatment significantly. 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 3 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 05/08/2024 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)