Circleville, OH

Circleville Post-Acute

4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

1155 Atwater Avenue, Circleville, OH

(740) 477-1695

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

97

Certified beds

Average residents

86

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pacs Group

Operator or chain grouping

Approved since

1980-03-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

264 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.66

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.80

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.03

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.49

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.46

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

2.91

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.31

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.46

CMS adjusted RN staffing hours

Adjusted total hours

2.47

CMS adjusted total nurse staffing hours

Case-mix index

1.93

Higher values indicate more complex resident acuity

RN turnover

31%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

42%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,819

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

22.41

Composite VBP score used to determine payment impact.

Payment multiplier

0.9829

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.82

Baseline 20.39% · Performance 20.12% · Measure score 2.82 · Achievement 2.82 · Improvement 0.29

Healthcare-associated infections

3.39

Baseline 8.73% · Performance 7.28% · Measure score 3.39 · Achievement 1.86 · Improvement 3.39

Total nurse turnover

2.75

Baseline 55.26% · Performance 52.44% · Measure score 2.75 · Achievement 2.75 · Improvement 0.43

Adjusted total nurse staffing

0

Baseline 2.64 hours · Performance 2.66 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.84%	10.72% 1.9 pts better	No Different than the National Rate · Eligible stays 58 · Observed rate 1.72% · Lower 95% interval 5.46%
Discharge to community	28.22%	50.57% 22.4 pts worse	Worse than the National Rate · Eligible stays 31 · Observed rate 12.9% · Lower 95% interval 18.14%
Medicare spending per beneficiary	0.9	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 54 · Denominator 54
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 54
Discharge self-care score	81.82%	53.69% 28.1 pts better	Numerator 27 · Denominator 33
Discharge mobility score	60.61%	50.94% 9.7 pts better	Numerator 20 · Denominator 33
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 54 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.28%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 37 · Observed rate 8.11% · Lower 95% interval 4.02%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 142
Staff flu vaccination coverage	1.25%	42% 40.8 pts worse	Numerator 2 · Denominator 160
Discharge function score	84.85%	56.45% 28.4 pts better	Numerator 28 · Denominator 33
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	4.17%	25.2% 21 pts worse	Numerator 1 · Denominator 24

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.6	1.8 0.8 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.4 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.0	1.8 0.2 pts worse	1.8 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	92.4% 7.3 pts better	93.4% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.9%	94.5% 4.4 pts better	95.5% 3.4 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.3% 3.3 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	99.0%	26.1% 72.9 pts worse	11.4% 87.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.6% · Q3 98.6% · Q4 100.0% · 4Q avg 99.0%
Percentage of long-stay residents who lose too much weight	5.7%	6.2% 0.5 pts better	5.4% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 7.0% · Q3 2.9% · Q4 2.9% · 4Q avg 5.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	32.7%	25.4% 7.3 pts worse	19.6% 13.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 29.6% · Q3 34.8% · Q4 37.7% · 4Q avg 32.7%
Percentage of long-stay residents who received an antipsychotic medication	7.5%	11.5% 4 pts better	16.7% 9.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.8% · Q3 9.8% · Q4 3.6% · 4Q avg 7.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	0.0%	7.7% 7.7 pts better	16.3% 16.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	0.4%	6.2% 5.8 pts better	14.9% 14.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.2% 0.2 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	0.5% 0.4 pts worse	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 1.3% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.7%	21.7% 6 pts worse	19.8% 7.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 44.9% · Q3 15.2% · Q4 27.0% · 4Q avg 27.7%
Percentage of long-stay residents with pressure ulcers	0.9%	3.7% 2.8 pts better	5.1% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.7% · Q3 0.8% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.1%	78.1% 20 pts better	81.7% 16.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 92.3% · 4Q avg 98.1%
Percentage of short-stay residents who had an outpatient emergency department visit	17.2%	12.5% 4.7 pts worse	12.0% 5.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 17.5% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.5%	1.2% 2.3 pts worse	1.6% 1.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 3.8% · Q4 10.0% · 4Q avg 3.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.7%	75.6% 22.1 pts better	79.7% 18 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	17.4%	25.1% 7.7 pts better	23.9% 6.5 pts better	Short Stay · 20240701-20250630 · Adjusted 17.4% · Observed 20.0% · Expected 27.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-17 · Fire 2025-04-17

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2022-09-26 · Fire 2022-09-26

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2020-01-02 · Fire 2020-01-02

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-17

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-05-09

E · Potential for more than minimal harm 2025-04-17

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-05-09

F · Potential for more than minimal harm 2022-09-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-10-19

E · Potential for more than minimal harm 2022-09-26

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2022-10-19

E · Potential for more than minimal harm 2022-09-26

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-10-19

E · Potential for more than minimal harm 2022-09-26

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2022-10-19

E · Potential for more than minimal harm 2022-09-26

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-10-19

F · Potential for more than minimal harm 2020-01-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2020-02-20

F · Potential for more than minimal harm 2020-01-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2020-02-20

E · Potential for more than minimal harm 2020-01-02

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2020-02-20

E · Potential for more than minimal harm 2020-01-02

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2020-02-20

E · Potential for more than minimal harm 2020-01-02

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2020-02-20

E · Potential for more than minimal harm 2020-01-02

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2020-02-20

E · Potential for more than minimal harm 2020-01-02

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2020-02-20

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-04-17

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-05-09

D · Potential for more than minimal harm 2025-04-17

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-05-09

D · Potential for more than minimal harm 2025-04-17

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-05-09

D · Potential for more than minimal harm 2025-04-17

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2025-05-09

D · Potential for more than minimal harm 2025-04-17

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-05-09

E · Potential for more than minimal harm 2022-09-26