Pickaway Manor Care Center

Inspectors wroteBased on record review, observation, resident and staff interviews, wound physician interview, review of wound notes, review of hospital records, review of information from the National Pressure Injury Advisory Panel (NPIAP), review of specifications for air mattresses, and policy review, the facility failed to ensure the physician ordered treatments were completed as directed and failed to ensure interventions were implemented to prevent the development of, worsening of and promote the healing of an avoidable facility acquired pressure ulcer for Resident #5. Resident #5 was at risk for pressure ulcer development and dependent on staff for activities of daily living (ADLs) including transfers, and toileting and required max assist with bed mobility, turning and repositioning, and had a known sacrum stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to implement and maintain a comprehensive Quality Assurance Improvement Program (QAPI) program and plan to address care issues and/or concerns in the facility. This had the potential to affect all 84 residents who reside in the facility. The facility census was 84. Review of the Quality Assurance (QA) committee attendance records for the previous 12 months revealed QA meetings were held at the end of each month starting with January 2025. Specifically for the September 26, 2025, meeting, review of prevention/interventions for residents with pressure ulcers were discussed, but Resident #41 and Resident #5 were not discussed separately and identified as ongoing issues with their care. [...]

Inspectors wroteBased on observation, staff interview, and review of facility provided food storage policies, the facility failed to ensure food was protected from potential spoilage and/or contamination in the areas of food storage and food preparation. This had the potential to affect all 83 residents who received food from the kitchen. The facility census was 84.

Inspectors wroteBased on medical record reviews, interviews, and facility policies, the facility failed to ensure Licensed Practical Nurses (LPN's) acted within their professional standards and their scope of training related to pressure ulcer wound assessments and staging's. This affected four Residents (#5, #41, #99, and #82) out of six reviewed for pressure ulcer assessments and staging's by facility staff. The facility census was 84. 1. Review of the medical record for Resident #5, revealed an admission date of 12/3/24. Diagnoses included but were not limited to type 2 diabetes, central cord syndrome at cervical 5 level of cervical spinal cord, specified disorder of muscle, generalized anxiety disorder and major depressive disorder. [...]

Inspectors wroteBased on medical record reviews, observations, interviews, and facility policies, the facility failed to perform hand hygiene before and after wearing contact precautions when passing a lunch tray to Resident #21. This had the potential to affect 5 other residents at the facility in contact precautions who received lunch trays for meals. The facility also failed to ensure enhanced barrier precautions were ordered timely for eight Residents (#5, #41, #99, #46, #64, #52, and #82) out of eight who required enhanced barrier precautions. This had the potential to affect 5 other residents in enhanced barrier precautions. The facility census was 84.1. Review of the medical record for Resident #21 revealed the resident was admitted on [DATE] with diagnoses that included severe chronic kidney disease, acidosis, and anemia amongst other diagnoses. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain a resident's call light within reach. This affected one resident (#25) of one sampled for call light placement. The facility census was 84.

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall interventions as ordered. This affected two residents (#38 and #84) of two sampled for falls. The facility census was 84. Findings Include: 1. Review of Resident #38's medical record revealed an admission date of 07/30/20, a re-entry date of 11/25/23, and diagnoses including chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, vascular dementia, anxiety disorder, and congestive heart failure. Review of Resident #38's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status score (BIMS) of 13 indicating the resident was cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to properly maintain an indwelling catheter for one resident (#21) of one sampled for catheter use. The facility census was 84.

Inspectors wroteBased on medical record review, and staff interview, this facility failed to ensure meal intakes were being monitored to ensure residents highest nutritional status. This affected one (Resident #84) of the one resident reviewed for nutrition. The facility census was 84.

Inspectors wroteBased on medical record review, staff interview, and dialysis communication documents, this facility failed to ensure orders and recommendations for residents receiving dialysis services were followed. This affected one (Resident #84) of the one resident reviewed for dialysis. The facility census was 84.

Inspectors wroteBased on medical record review, hospital record review, review of the University of Pittsburgh Medical Center information, review of facility policy and procedures, and staff interviews, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition on 05/21/25 involving Resident #22, when the resident was assessed to have a decline in health including lethargy, a poor appetite, confusion, increased hallucinations, and low oxygen saturation, without evidence of timely or adequate interventions and medical treatment. This resulted in Immediate Jeopardy and serious life-threatening harm, and/or injuries when Resident #22 developed new deep tissue injuries (DTIs) and suffered a continued decline in health status. [...]

Inspectors wroteBased on record review, review of a video recording from an in-room camera, family interview, staff interview, and policy review, the facility failed to honor a resident's known preference on not having a male caregiver assist her with personal care. This affected one (#73) of three residents reviewed for choices/personal preference. The facility census was 71.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) documents were accurate. This affected one (Resident #56) out of one resident reviewed for PASRR documents. The census was 75.

Inspectors wroteBased on medical record review, observations, and staff interview, the facility failed to ensure catheter tubing was stored properly/appropriately to prevent the spread of infection. This affected one (Resident #283) out of one resident reviewed for urinary catheters. The facility census was 75.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.