Piqua Manor

In the surveyor’s words

From the most serious findings on record at Piqua Manor, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 1, 2023

  Based on medical record review, staff interview, review of the fall investigation, and policy review, the facility failed to ensure care was provided in a manner to prevent an avoidable fall with injury and was not initially thoroughly investigated to determine the root cause analysis to identify potential hazards to reduce and/or eliminate falls with major injury. This resulted in Actual Harm when State tested Nurse Aide (STNA) #114 stepped away from the bedside while providing care for Resident #78. Subsequently, Resident #78 slid or rolled from the bed and landed on her knees complaining of right knee pain. Resident #78 was sent to the hospital where it was determined both femurs had been fractured resulting in surgical intervention. […]

• No harm, potential for more than minimal, widespreadF812Mar 26, 2026

  Based on observation, staff interview, and policy review, the facility failed to store food in a safe manner. This had the potential to affect all residents who received food from the kitchen. The facility identified four (#12, #38, #85, and #98) residents who received nothing by mouth. The census was 87.Findings include: Observation of the kitchen on 03/23/26 at 7:55 A.M., during the initial tour with Nutrition Services Assistant (NSA) #48, revealed three storage refrigerators not in temperature range to prevent food-borne illnesses. […]

• No harm, potential for more than minimal, isolatedF880Jul 1, 2026

  Based on record review, observation, interviews, and facility policy review, the facility failed to ensure staff completed hand hygiene. This affected three residents, (#02, #07, and #17) of three reviewed for infection control. The facility census was 90. Findings Include: 1. Review of medical record for Resident #02 revealed the resident was admitted to the facility on [DATE]. Diagnoses included epilepsy, neuromuscular dysfunction of bladder, atrial fibrillation, and obesity. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #02 had Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. Resident #02 was dependent on dressing her lower body and toileting hygiene. […]

• No harm, potential for more than minimal, isolatedF558Mar 26, 2026

  Based on observation, resident interview, and staff interview, the facility failed to ensure a reasonable accommodations were made for a resident related to placement and use of a urinal in the resident's room. This affected one (#71) of one residents reviewed for accommodation of needs. The census was 87.Findings include:Observation on 03/23/26 at 9:28 A.M. revealed a urinal with 1000 milliliters (mls) of urine inside was placed on a bedside tray table in Resident #71's room, the same surface utilized for meals and personal items. Resident #71's medication and personal items were sitting on bedside tray at the time of the observation.Interview on 03/23/26 at 9:28 A.M. […]

• No harm, potential for more than minimal, isolatedF578Mar 26, 2026

  Based on paper and electronic medical record review, staff interview, and policy review, the facility failed to ensure the resident's code status was consistent throughout the entire medical record. This affected one (#103) of one residents reviewed for advanced directives. The census was 87. Findings include: Review of Resident #103's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including urinary tract infection, hypertensive chronic kidney disease, type II diabetes, unspecified dementia, atrial fibrillation, and peripheral vascular disease. […]