Health inspection·July 22, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was transported to a local hospital, then transferred to a larger hospital where she was admitted for treatment of admitting diagnoses of adrenal crisis, human meta pneumatic pneumonia with septic shock, acute hypoxic respiratory failure, and acute metabolic encephalopathy. Resident #22 received treatment in the intensive care unit (ICU) and was intubated requiring a ventilator for breathing from 05/29/25 until 06/02/25. The Immediate Jeopardy was removed on 07/15/25 when the facility implemented the following corrective actions: On 05/29/25, Resident #22 was sent to the emergency room (ER) and returned to the facility 6/09/25 and continues to receive dialysis three times weekly. On 07/14/25, Resident #22's clinical assessment was completed by LPN #133 and was noted to be within normal limits for this resident. On 07/14/25, LPN #129 (the nurse responsible for Resident #22's direct care on 05/28/25 when the resident's O2 saturation dropped to 71%) was re-educated by the DON on Change in Condition Notification policy and procedure with emphasis on documentation relative to resident's change in condition in medical record related to resident's progress notes in the medical record. On 07/14/25, the DON/Designee reviewed 13 residents in the 30 day look back period for notification of change in condition. On 07/14/25, all current residents (87 residents) in the facility were reviewed by the DON/Designee for change in condition/notification. Any issues identified were corrected at the time of discovery. This was completed prior to 1:30 P.M. on 07/14/25. Beginning on 07/14/25, resident Progress Notes will be reviewed by the DON/Designee daily to ensure all notification and new orders are documented for all residents change in condition. E-interact Change in Condition user defined assessment (UDA) documentation is separated into three sections. Section 1 includes signs and symptoms identified, vital sign evaluation, general background information. Section 2 includes resident evaluation which includes mental status evaluation and functional status evaluation, based on signs and symptoms identified, other body system domains can be assessed. Section 3 includes a review of information and provider notifications. E-interact Change in Condition UDA will be reviewed daily for all residents who are identified with a change in condition by the DON/Designee to ensure all new orders and notifications are documented. On 07/14/25, the DON/Designee educated facility nursing staff on Change in Condition Notification policy and procedure by 2:30 P.M. on 07/14/25. Three (3) registered nurses (RNs) were educated in house, seven (7) RNs were educated via phone, seven (7) LPNs were educated in house, nine (9) LPNs were educated via phone, 11 certified nurse aides (CNA)s were educated in house, 44 CNAs were educated via phone. All RNs, LPNs, and CNAs that were educated via phone must sign off on education prior to working their next shift. Beginning on 07/14/25, Progress Notes will be reviewed on all current residents by the DON/Designee daily to ensure all notification and new orders are documented for residents change in condition. E-interact Change in Condition UDA documentation will be reviewed daily for all residents by the DON/Designee to ensure all new orders and notifications are documented. On 07/14/25 at 4:00 P.M., a meeting was conducted with DON, ADON, LPN #129, Regional Nurses, Medical Director and Administrator to review the incident for Resident #22. Education was provided to LPN #129 regarding change in condition and notification documentation in the medical record. On 07/14/25, the Change in Condition Notification policy was reviewed by the DON, Senior [NAME] President of Clinical Services, Medical Director, and RCSD #170 to ensure the policy was comprehensive and accurate. There were no changes made at this time. Beginning on 07/15/25, audits will be completed by the DON/Designee daily for two weeks, then five times per week for two weeks, then three times per week for two weeks, then two times per week for two weeks, then PRN (as needed) to ensure change in condition notification occurs timely. Beginning on 07/15/25, results of the audits will be forwarded to the Quality Assurance Performance Improvement Committee meeting by the DON/Designee monthly for three months for immediate follow up. On 07/15/25 at 2:01 P.M., 2:03 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365556 If continuation sheet Page 2 of 8 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 07/22/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few P.M., 2:05 P.M., 2:09 P.M., and 2:11 P.M., interviews with CNA #111, CNA #120, CNA #108, LPN #180, and LPN #115 revealed the staff had received education from the facility on resident change in condition and notification.? The CNAs interviewed reported that if they identify a change in a resident's condition, they are to report that to the nurse. If the nurse doesn't address it (assess the resident), the CNA will report the resident change in condition up the chain of command (manager). The LPNs that were interviewed revealed they had received education on resident change in condition and notification.? The LPNs reported they are to complete comprehensive assessments of residents identified with a change in condition, report the change in condition to the resident's physician or medical provider (and the resident's family), receive orders, and can go up the chain of command if needed. Although the Immediate Jeopardy was removed on 07/15/25, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, rheumatoid arthritis, chronic embolism and thrombosis of other specific veins and tachycardia. Review of an order dated 08/17/22 revealed Resident #22 had a Do Not Resuscitate Comfort Care Arrest (DNRCCA) in place. The order was discontinued on 06/03/25. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22's cognition remained intact, she had no behaviors (including hallucinations), she needed set-up help for eating and oral hygiene, was dependent for toileting hygiene, required maximum assistance for bathing and lower body dressing, moderate assistance for upper body dressing, and required supervision for personal hygiene. Resident #22 was also identified to be at risk for pressure ulcers. Review of a note dated 05/21/25 at 8:11 A.M. by LPN #129 revealed during routine skin care, new deep tissue injuries (DTIs) were noted to Resident #22's right flank and right upper thigh as well as a skin tear to her right flank. Resident #22 did not have complaints of pain to the areas and there were no signs or symptoms of infection noted. The skin tear was cleaned with normal saline, patted dry, xeroform and foam dressing were applied and the DTIs had triad paste applied. Resident #22 was noted to have a decline in health, went to dialysis three times a week, and received a new order to have a blanket between her and the Hoyer pad. Resident #22's physician (#166) and responsible party were made aware. There were no new orders. Review of vital signs taken on 05/21/25 at 11:39 P.M. revealed Resident #22 had respirations of 16 breaths per minute, a pulse of 68 beats per minute (bpm), oxygen saturation of 93% on room air, and a blood pressure of 102/60 mm/Hg. Review of a nursing note dated 05/22/25 at 6:43 A.M. by LPN #133 revealed Resident #22 was up and hallucinating most of the night about men fighting in her room, and the dialysis nurses laughing at her and shaking her chair. One-on-one intervention was attempted resulting in a brief discussion with Resident #22 who would then return to hallucinations and asked the nurse to get the men out of her house. There was no evidence that the resident's physician was notified. Review of vital signs taken on 05/22/25 at 12:02 P.M. revealed Resident #22 had a blood pressure of 87/46 mm/Hg, pulse of 78 bpm, and oxygen level and respirations were not checked. Review of a nursing note dated 05/22/25 at 12:55 P.M. by LPN #129 revealed Resident #22 was noted to have increased confusion and was talking about people in her bathroom. No other concerns were noted and there was no evidence the physician was notified. Review of a nursing note dated 05/23/25 at 7:47 A.M. by LPN #129 revealed dialysis called and stated their physician would like to discontinue Resident #22's order for nifedipine (medication used to treat high blood pressure). Resident #22, responsible party and the physician were made aware. There were no new orders. Review of vital signs for 05/23/25 revealed Resident #22's vital signs were not checked. Review of a nursing note (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365556 If continuation sheet Page 3 of 8 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 07/22/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few dated 05/24/25 at 11:19 A.M. by Registered Nurse (RN) #117 revealed Resident #22 was resting in bed with her eyes closed, she was lethargic but did wake up when spoken to. Resident #22 received her medications and skin treatments. There was no evidence that Resident #22's physician was notified she was lethargic. Review of Resident 22's vital signs taken on 05/24/25 at 1:39 A.M. revealed a blood pressure of 86/50 mm/Hg, at 7:51 A.M. a blood pressure of 81/59 mm/Hg, at 11:28 A.M. a blood pressure of 93/64 mm/Hg and a pulse of 62 bpm, and at 10:44 P.M. Resident #22 had a blood pressure of 103/59 mm/Hg. Resident #22's oxygen level and respirations were not checked. Review of vital signs taken on 05/25/25 revealed Resident #22 had a blood pressure of 97/62 mm/Hg at 8:24 A.M., 92/68 mm/Hg at 1:16 P.M. and a pulse of 69 bpm, and a blood pressure of 97/64 mm/Hg at 10:29 P.M.; however, oxygen saturation and respirations were not checked. Review of vital signs taken on 05/26/25 revealed Resident #22 did not have her respirations or oxygen saturation checked; her pulse was 72 bpm at 12:05 P.M.; and her blood pressure was 121/70 mm/Hg at 9:55 A.M., 112/70 mm/Hg at 12:05 P.M., and 106/64 mm/Hg at 10:55 P.M. Review of a nursing note dated 05/27/25 at 12:45 P.M. by LPN #115 revealed Resident #22 had a very poor appetite and the nurse attempted to help the resident put her medications in her mouth because Resident #22 kept dropping her pills and water. LPN #115 had to pick up the pills from the bed a couple of times. Resident #22 denied pain and was in bed with her eyes closed most of the morning. There was no evidence that Resident #22's physician was notified. Review of vital signs taken on 05/27/25 revealed Resident #22 had a blood pressure of 100/58 mm/Hg at 10:18 A.M., 97/57 mm/Hg at 12:20 P.M., and 90/52 mm/Hg at 11:34 P.M.; her oxygen saturation was not checked; her pulse was 68 bpm at 12:20 P.M.; and her respirations were not checked. Review of a nursing note dated 05/28/25 at 3:31 P.M. by LPN #129 revealed Resident #22 was noted to have blue fingertips when she returned from dialysis. Oxygen was applied at two liters per minute via nasal cannula and Resident #22 was minimally responsive. Resident's oxygen saturation was 71%. When LPN #129 went back to recheck oxygen levels after applying oxygen, the machine could not get a reading. Resident #22's fingers were cool, and LPN #129 attempted to warm her fingers with no success. The resident's responsible party was notified and requested a hospice consult. Resident #22's physician (#166) was notified and gave no new orders. Vital signs taken on 05/28/25 revealed Resident #22's respirations were 16 breaths per minute at 11:24 P.M.; her pulse was 78 bpm at 12:28 P.M. and 70 bpm at 11:24 P.M.; her oxygen saturation was 93% at 11:24 P.M. with oxygen via nasal cannula; and her blood pressure was 101/72 mm/Hg at 12:28 P.M. and 104/56 mm/Hg at 11:23 P.M. Review of a nursing note dated 05/29/25 at 1:18 A.M. by LPN #133 revealed Resident #22 was resting in bed with her eyes closed. She was confused and unable to communicate her needs. Vital signs were within normal limits and respirations were even and unlabored with oxygen in place. Resident #22 did need to be fed her meals. Care was provided per the plan of care. There was no evidence that Resident #22's physician was notified of the resident's confusion and need for assistance with meals. Review of a nursing note dated 05/29/25 at 6:29 A.M. by LPN #133 revealed Resident #22 continued to have blue fingertips and nail beds. Resident #22 was receiving oxygen at two liters per minute via nasal cannula. LPN #133 was able to warm Resident #22's fingers enough to get an oxygen reading of 93%. Resident #22 was very confused and having hallucinations, it took much coaxing to get her to take her pills but after three attempts, Resident #22 did take her medications. There was no evidence that the Resident #22's physician was notified of her blue fingers, hallucinations, and confusion. Review of a nursing note dated 05/29/25 at 8:04 A.M. by LPN #129 revealed Resident #22 had two appointments scheduled for vein mapping on this date but she refused to go because she was too tired. Resident #22 had a decline in health, fingertips were blue, oxygen was in place, and she was having hallucinations. Resident #22 requested to have her appointments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365556 If continuation sheet Page 4 of 8 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 07/22/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few rescheduled and both offices were called. Resident #22's responsible party and physician were notified. There were no new orders. Review of vital signs taken on 05/29/25 revealed Resident #22's blood pressure was 106/62 mm/Hg at 8:47 A.M. and 76/57 mm/Hg at 9:29 P.M.; her oxygen was 93% at 12:16 A.M. and 92% at 2:50 P.M. both with oxygen via nasal cannula; her pulse was not documented; and her respirations were not documented. Review of a nursing note dated 05/29/25 at 9:30 P.M. by LPN #122 revealed upon entering Resident #22's room, she had blue fingertips, and they were unable to get an oxygen reading. Resident #22's blood pressure was also very low at 76/57 mm/Hg, and she had a pulse of 51 bpm. She was very confused and having a hard time putting sentences together. Resident #22's physician was made aware and gave orders to send to the emergency department for evaluation. Nine-one-one (911) was called and Resident #22's responsible party was notified. Upon emergency medical services (EMS) arrival, they obtained her blood sugar which was 56 mg/dL, and they could not obtain a blood pressure. Review of a nursing note dated 05/30/25 at 3:08 A.M. by LPN #122 revealed the nurse at the emergency room notified her Resident #22 was being transferred to a larger hospital with concerns of adrenal crisis. All parties were made aware. Review of a nursing note dated 05/30/25 at 3:51 A.M. by LPN #122 revealed Resident #22 also had elevated troponin, TSH, an acute urinary tract infection (UTI), and hypoglycemia. All parties were made aware. Review of a nursing note dated 06/09/25 at 3:18 P.M. by LPN #129 revealed the physician, ambulance and dialysis were all notified of Resident #22's readmission to the facility. Review of a hospital Discharge summary dated [DATE] at 11:42 A.M. revealed Resident #22 presented to a local emergency room on [DATE] for confusion, hypoglycemia, and she was transferred to this hospital for a concern of adrenal crisis. Resident #22 was admitted to the intensive care unit, and she had acute hypoxic respiratory failure with intubation and septic shock. Her admitting diagnoses were secondary adrenal insufficiency, septic shock with a UTI, Human Metapneumovirus/Strep/E.coli Pneumonia (E.coli and proteus were in her urine, E.coli was in her sputum, and pneumonia had strep), acute hypoxic respiratory failure and was intubated on arrival due to mental status, extubated on 06/02/25 and weaned to room air, and acute metabolic encephalopathy. Review of a MDS dated [DATE] revealed Resident #22's cognition remained intact, she had no behaviors, and she required set up for eating, supervision for oral hygiene, dependent on staff for toileting hygiene, maximum assistance for bathing, moderate assistance for upper body dressing, maximum assistance for lower body dressing, dependent on staff for applying footwear, and maximum assistance for personal hygiene. Interview on 07/11/25 at 2:08 P.M. with Certified Nursing Assistant (CNA) #101 revealed Resident #22 was super, super confused for a while. She was unsure why Resident #22 was hospitalized . Interview on 07/11/25 at 2:13 P.M. with LPN #115 revealed that if she encountered a resident with a low oxygen saturation, she would apply oxygen or a bipap and call the doctor immediately because that is a sign of respiratory distress/exacerbation. LPN #115 stated the facility does not normally treat respiratory distress. LPN #115 stated if she was unable to get a resident's oxygen reading, she would grab another machine, and if she still couldn't, she would send the resident to the hospital immediately using her nursing judgement, then call the doctor. LPN #115 stated Resident #22 made her own decisions for a long time; however, when she started dialysis, she would talk with her brother to make decisions, then she was so confused she could not make decisions. LPN #115 stated Resident #22 is better now and making her own choices. Interview on 07/11/25 at 2:25 P.M. with LPN #129 revealed she was the nurse on 05/28/25 providing care to Resident #22 when Resident #22's oxygen level was at 71%. LPN #129 stated when someone has low oxygen, she applies oxygen, calls the physician and follows orders. LPN #129 stated Resident #22 was not on oxygen prior to 05/28/25 and had no history of using ventilators or oxygen. LPN #129 confirmed Resident #22 having low oxygen levels was a big (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365556 If continuation sheet Page 5 of 8 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 07/22/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few change for her. LPN #129 stated she tried to warm Resident #22's fingers and she spoke with dialysis who also noted she had blue fingertips. LPN #129 stated Resident #22 was making her own decisions until she had a decline. LPN #129 stated she does not make any decisions without talking to the doctor first and it is up to the doctor to determine if someone needs to go to the hospital or not. LPN #129 stated if she did not document anything in her notes, the physician did not give orders at the time. LPN #129 also confirmed multiple notes did not indicate the physician was notified of Resident #22's change in status. Interview on 07/11/25 at 2:43 P.M. with LPN #110 revealed if a resident had blue fingers and an oxygen saturation level of 71%, it would likely be a medical emergency. LPN #110 stated his course of action would be to apply oxygen even if the residents do not have an as needed order because they are obviously in distress, reach out to the doctor, and more than likely call 911. When asked if the resident had a full code status or DNRCCA in place and the doctor did not give orders to send out, LPN #110 stated he would use his nursing judgement to send a resident in respiratory distress out (to the hospital to be evaluated). Interview on 07/11/25 at 3:33 P.M. with Physician #166 revealed he could not recall specifically what the facility did or did not make him aware of regarding Resident #22. Physician #166 stated he could not recall why he did not give new orders to send Resident #22 to the hospital. Physician #166 stated it was likely the facility administered oxygen and her saturation went up. When informed the nurse could not get a follow up reading (oxygen saturation) on Resident #22, Physician #166 did not have a response. Physician #166 stated if the facility called him regarding Resident #22 having hallucinations, out of every resident in the building, he would care the least about her having hallucinations because she is schizophrenic and has hallucinations at times. When asked about worsening hallucinations in conjunction with other symptoms such as low oxygen levels, poor appetite and lethargy, Physician #166 stated she's always discolored, I don't know if they document that though. Interview on 07/11/25 at 3:52 P.M. with Dialysis Manager (DM) #150 revealed the dialysis center had noticed a decline in Resident #22's health as well. DM #150 stated prior to 05/21/25, they had sent Resident #22 to the hospital multiple times, and they were unable to identify a problem and would send her back. DM #150 stated when Resident #22 went to the hospital on [DATE], she did not think she would ever come back but she is like a whole new person since her recovery. DM #150 reviewed notes at this time and revealed on 05/16/25, a discussion about Resident #22's low blood pressure was had, and a referral was sent to cardiology as well as new orders to take blood pressure twice daily from Friday-Sunday. On 05/19/25, the dialysis physician rounded and decreased blood pressure medications and a message was left with the facility to update them on the new orders. On 05/21/25, an order was received to discontinue nifedipine (blood pressure medication) due to low blood pressures. On 05/23/25, DM #150 spoke with the facility who did not stop the nifedipine but would discontinue it immediately and monitor blood pressures. On 05/28/25, dialysis called the facility for a medication change due to a need to discontinue atenolol and start Coreg. DM #150 stated dialysis is not required to check oxygen levels, but they did notice Resident #22 had some discoloration to her fingers. Interview on 07/14/25 at 8:40 A.M. with Resident #22 revealed she was unable to recall the entire timeframe she was sick, she does not know when it started or when she was sent out. Resident #22 stated this was abnormal for her because she usually knows what's going on. Resident #22 stated she asked the facility what happened, but they didn't tell her. Resident #22 stated it was like out of nowhere she took a nosedive. Resident #22 stated she does have a history of hallucinations, but it is not anything too bad. Resident #22 stated it is not normal for her to be lethargic, confused, have a poor appetite, have blue fingertips, or unable to form sentences. Resident #22 stated she had never needed to wear oxygen prior to her illness. Interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365556 If continuation sheet Page 6 of 8 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 07/22/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 07/14/25 at 8:54 A.M. with LPN #133 revealed she worked with Resident #22 throughout the timeframe of 05/21/25 through 05/29/25. LPN #133 stated it was normal for Resident #22 to have hallucinations. LPN #133 stated during a certain period of time, it was Resident #22's baseline to be confused, unable to communicate, and blue fingertips. LPN #133 stated Resident #22's confusion and lethargy were due to dialysis. Interview on 07/14/25 at 10:06 A.M. with LPN #122 revealed she worked with Resident #22 the night she was sent out. LPN #122 stated she sent Resident #22 out on 05/29/25. LPN #122 stated when she reported for her shift, she was informed Resident #22 wasn't doing very well, had to be fed her meals, was on oxygen now, and her fingers were blue. LPN #122 stated the aides got her during the night because Resident #22 was out of it and her fingers were super blue. LPN #122 stated Resident #22 did not know where she was, thought she was seeing her dead son and calling out for him. LPN #122 stated she got one low blood pressure but could not recall what it was. When she attempted to recheck the blood pressure, she was unable to get one at all. LPN #122 stated she called Physician #166 who gave the order to send Resident #22 to the hospital. LPN #122 stated EMS came and they could not get blood pressure either and made the comment they had never seen their blood pressure cuff go so low. LPN #122 stated her initial thought was Resident #22 was in respiratory failure because her fingers were so blue. LPN #122 stated she worked with Resident #22 about one week prior to this incident and the resident had a major change (within that week). LPN #122 stated she was shocked because Resident #22 could make her own decisions for the most part with some confusion. Resident #22 had worse hallucinations than normal, and she does not hallucinate often unless something clinical is going on with her. LPN #122 stated Resident #22 never used oxygen before. LPN #122 stated since starting dialysis, Resident #22's blood pressure had been running lower, but not as low as it was during 05/29/25. LPN #122 stated Resident #22 was not diabetic and she would not have even considered checking her blood sugar. LPN #122 stated she reviewed the documentation for the previous week (05/21/25- 05/29/25) and was very frustrated with everything and thought if Resident #22 had gone out several days sooner, she may not have needed to be intubated. LPN #122 stated a comment was made Resident #22 was a DNRCCA and waiting for a hospice consult; however, Resident #22 stated she was not ready to die. LPN #122 stated if she had been working while Resident #22's oxygen was 71%, she would have called the doctor to get orders and send her out. If the doctor did not give the order, LPN #122 would have used nursing judgement and sent her anyway. Interview on 07/14/25 at 10:27 A.M. with RN #117 revealed she does not often work the floor but knew Resident #22 has had blood pressure issues and wasn't feeling well since starting dialysis. RN #117 stated Resident #22 had no complaints, but she was lethargic when she worked with her. RN #117 stated she was sure she notified the physician and notification should be documented. Review of a statement dated 07/14/25 by LPN #129 revealed Resident #22's physician was notified about the change of condition on 05/28/25 and was in agreeance that resident had been declining over the last few weeks after starting dialysis. The physician gave the okay for Resident #22 to have oxygen and for a hospice consultation. No other orders were given at that time. (This was not part of Resident #22's medical record). Review of an undated statement by Physician #166 revealed regarding the timeframe of 05/22/25 through 05/29/25 relating to Resident #22's health, he was kept aware of her condition and goals through verbal reports, Resident #22 had been weighing the option of hospice and at no point did Physician #166 feel he was inadequately made aware of Resident #22's condition and the timing of the ER visit and hospitalization on 05/29/25 was not inappropriate to the overall clinical scenario. Review of a policy titled Change in Condition dated 08/09/23 revealed the nurse will notify the resident, their physician, and a representative when there is a change in condition including a significant change in the resident's physical, mental or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365556 If continuation sheet Page 7 of 8 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 07/22/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete psychosocial status such as deterioration which includes life-threatening conditions or clinical complications. The nurse will document in the resident's medical record information relative to the resident's change in condition and a comprehensive assessment will be completed if the change is significant. The definition of significant change in condition means the condition will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and it impacts more than one area of the resident's health status and requires interdisciplinary review and/or revision to the care plan. Immediately is determined to be as soon as practicable after the resident has been adequately assessed, necessary emergent care or treatment is rendered, and the resident's safety has been secured. Review of the University of Pittsburgh Medical Center website (https://www.upmc.com/services/divsion-infectious-diseases/conditions/sepsis) dated 2025 revealed the six main symptoms of sepsis are shortness of breath; fever, chills, or feeling very cold; high heart rate or low blood pressure; extreme pain or discomfort; sweaty or clammy skin; and being confused or feeling a bit lost.? Sepsis is an emergency blood infection that can lead to death within hours without proper treatment.? Sepsis can progress quickly and cause death within 12 hours and the risk of death increases by 7.6% for every hour that passes without treatment and getting quick treatment can be the difference between life and death.? Four types of infection that are more likely to lead to sepsis include pneumonia, a UTI, skin infections and gut infections. Those at a higher risk for sepsis include people 65 or older, weakened immune systems, have had a recent severe illness or hospital stay, or chronic illnesses such as lung disease or kidney disease.? This deficiency represents non-compliance investigated under Complaint Number 1356449. Event ID: Facility ID: 365556 If continuation sheet Page 8 of 8