Pickerington Care And Rehabilitation

F 0583 Level of Harm - Minimal harm or potential for actual harm

At that time, STNA #183 tapped the door which was held with the fire release holder and the door easily swung and closed. The CNA confirmed Resident #52 should have received privacy during care. Review of facility policy titled Resident Rights dated 06/01/24, revealed the resident had the right to privacy and confidentiality during medical treatment and personal care.This deficiency represents non-compliance investigated under Complaint Number 1260918.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pickerington Care and Rehabilitation

1300 Hill Road North Pickerington, OH 43147

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 0584 Level of Harm - Minimal harm or potential for actual harm

Observations on 09/22/25 from 1:55 to 2:10 P.M. revealed after the interview with CNA #111, CNA #111 did not obtain supplies to clean the dirty mat on the wall and was not seen alerting other staff to clean the area.

Observation on 09/22/25 at 2:30 P.M. revealed Resident #25's wall mat remained soiled with the dried brown substance.

Residents Affected - Few

Observations on 09/23/25 at 8:35 A.M. and 9:10 A.M. revealed Resident #25's wall mat remained soiled with the dried brown substance.

Observation on 09/23/25 at 9:55 A.M. revealed Resident #25's wall mat was being cleaned by housekeeping staff.

Review of facility policy titled Resident Environmental Quality dated 11/29/22, revealed the facility shall maintain and provide a safe, functional, sanitary and comfortable environment for residents, maintain all essential patient care equipment in safe operating condition, and all facility personnel were responsible for reporting broken, defective equipment and furnishings upon identification.

This deficiency represents non-compliance investigated under Complaint Number 1260942.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pickerington Care and Rehabilitation

1300 Hill Road North Pickerington, OH 43147

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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Resident #80's long fingernails and the left-hand fingernails with a dark substance under the fingernails.

CNA #161 stated if long, dirty fingernails were observed, she would clean and cut the fingernails.

1. 3. Review of Resident #77's medical record revealed he was admitted to the facility on [DATE REDACTED]. Diagnoses

included acute respiratory failure, tracheostomy, diabetes, psoriasis, obstructive hydrocephalus, high blood pressure and gastrostomy.

Review of the quarterly minimum data set assessment dated [DATE REDACTED] revealed the resident was rarely/never understood. He was dependent for oral hygiene, toileting, shower/bathing, dressing, personal hygiene, and turning and repositioning. It further noted he was always incontinent of bowel and bladder.

Observations on 09/22/25 at 2:41 P.M. revealed Resident #77 fingernails and toenails were long and jagged. On 09/23/25 at 1:58 P.M. Resident #77 remained in bed with fingernails and toenails observed as long, thick and jagged.

On 09/23/25 at 3:30 P.M. observation of Resident #77's fingernails and toenails revealed they were thick, long and jagged. This was verified during an interview with Registered Nurse (RN) #194 at the time of the

observation.

Reviewed the facility policy titled Activities of Daily Living (ADLs) dated 01/01/25 revealed care and services will be provided for the following activities of daily living including bathing, dressing, grooming and oral care.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pickerington Care and Rehabilitation

1300 Hill Road North Pickerington, OH 43147

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

this happened 09/21/25 around 8:00 P.M. and she did not attempt to replace the catheter due to having no orders and also she did not contact the physician about getting orders for replacement. The RN revealed since Resident #32 did not have orders, he did not need the catheter but was unable to state why it was put

in place. Review of the record further revealed no mention or evidence related to how much urine was obtained after Resident #32 was without a Foley catheter from 09/21/25 around 8:00 P.M. to 09/22/25 around 12:00 P.M., for a total of 16 hours.Interview on 09/25/25 at 1:45 P.M. with the Administrator confirmed the facility did not have any evidence the residents Foley catheter output was measured from 07/2025, 08/2025, or 09/2025. Review of facility policy titled Notification of Changes dated 01/01/25 revealed facility shall promptly inform resident's physician when there was a change requiring notification.

These circumstances included accidents, significant changes, and circumstances that require a need to alter treatment.Review of facility policy titled Catheter Care dated 06/01/24 revealed facility shall ensure residents with catheters receive appropriate care. Catheter care shall be preformed each shift and as needed.Review of facility policy titled Comprehensive Care Plans dated 08/22/22 revealed facility shall develop and implement a comprehensive care plan for each resident. Factors identified by the interdisciplinary team in accordance with residents needs and preferences. The care plan shall describe services to be furnished, services that should be provided but were not due to resident expressing their right to refuse, specialized services resulting from the PASARR assessment, discharge goals and information, resident specific preferences and interventions related to trauma. The care plan shall be reviewed and revised after each comprehensive and quarterly assessment.This deficiency represents non-compliance investigated under Complaint Number 1260943.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pickerington Care and Rehabilitation

1300 Hill Road North Pickerington, OH 43147

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 0880 Level of Harm - Minimal harm or potential for actual harm

Review of the facility's policy titled Handwashing/Hand Hygiene undated revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.

This deficiency represents non-compliance investigated under Complaint Number 2575168.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pickerington Care and Rehabilitation

1300 Hill Road North Pickerington, OH 43147

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 - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 interviews, and record review, the facility failed to maintain flooring for two residents (#53 and #67) out of 25 residents observed for environment. Additionally, the facility failed to ensure carpeting throughout facility was maintained in clean and sanitary manner. This had the potential to affect all 71 facility residents.Findings include 1. Observation on 09/22/25 at 2:08 P.M. of Resident #53 and #67's room revealed flooring under and around the room air conditioner was peeling up about an inch off

the floor and about eight tiles were affected. Observation and interview on 09/23/25 at 12:10 P.M. with Maintenance Director (MD) #190 confirmed Resident #53 and #67's flooring was peeling up and stated he was aware of issues with flooring and was trying to get the broken flooring replaced in order of severity. He stated the facility had been working on replacing flooring and he had a list they were working through. He reported the facility had been working on the flooring for several months and had only completed five rooms.2. Observations from 09/22/25 from 8:00 A.M. to 4:45 P.M. and 09/23/25 from 8:20 A.M. to 12:00 P.M. found facility carpeting in hallways to be dirty with grime and dark staining showing tracks and old moisture stains outside each resident room and down the middle of the hallway and around the offices and nursing stations. Observation and interview on 09/23/25 at 12:10 P.M. with Maintenance Director (MD) #190 confirmed the carpet was dirty and stated they tried to clean it, but it did not work. He revealed the facility was trying to get it replaced and revealed the corporate office was reviewing options for replacement. MD #190 was unable to provide any evidence that facility had taken any steps for replacement including quotes or order confirmations. He revealed they had a carpet cleaner that was used once monthly to maintain the carpets but confirmed they did not maintain it in a sanitized and clean manner. Review of facility policy titled Resident Environmental Quality dated 11/29/22, revealed the facility shall maintain and provide a safe, functional, sanitary and comfortable environment for residents, maintain all essential patient care equipment in safe operating condition, and all facility personnel were responsible for reporting broken, defective equipment and furnishings upon identification. It stated preventative maintenance schedules should be in place to maintain the building and equipment to maintain a safe environment.This deficiency represents non-compliance investigated under Complaint Number 2575168 and Complaint Number

1. 1260918. Event ID:

Facility ID:

If continuation sheet