Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, family and staff interview, the facility failed to maintain a homelike environment for one
resident (#63) of 15 residents (#2, #30, #37, #55, #56, #60, #61, #76, #242, #292, #295, #297, #298 and
#302 ) the facility identified as requiring enteral feeding and five residents (#37, #56, #61, #62 and #297)
reviewed who had incontinent care products stored on the bathroom floor of 17 (#1, #58, #76, #242, #292,
#294, #295, #296, #298, #299, #302 and #303) the facility identified as requiring incontinent care products
on the E and F halls. The facility failed to maintain a home like environment by ensuring the water
temperature was in the correct range for three rooms (#60, #65 and #66) on the E and F halls. The total
facility census was 104.
Findings Include:
1. During an interview with the family of Resident #63 on 03/04/19 at 1:52 P.M. revealed there were
concerns as the room where Resident #63 resided did not maintain a home like environment as it was not
thoroughly cleaned and had tube feeding frequently found on the base of the tube feeding pole, sheets and
various other places. The family revealed they often have to clean off the tube feeding pole themselves. The
family stated the water temperature in the bathroom was very hot and the incontinent care products were
kept on the floor under the open sink for the roommate in the room, the family just stated it was just not
right.
During an observation and interview with the Respiratory Therapist (RT) #200 on 03/06/19 7:30 A.M., it was
confirmed the tube feeding pole for Resident #63 had tube feeding on the base of the pole and there was
tube feeding on the bedside chair next to the resident's bed. RT #200 verified the resident rooms are
cleaned by house keeping and the items cleaned included the floors, tables, bathrooms and poles and
bases of the poles.
2. During an observation of resident room [ROOM NUMBER] and interview with Licensed Practical Nurse
(LPN) #150 on 03/04/18 at 2:30 P.M. it was observed the water temperature of in the resident bathroom
sink was 122 Fahrenheit and there was no open package of incontinent care disposable chux opened on
the floor for resident use under the sink. LPN #150 confirmed the water temperature and the storage of
opened package of resident incontinent care products being stored on the floor under the sink.
During an observation of room [ROOM NUMBER] and interview with LPN #150 on 03/04/19 at 2:32 P.M.
the water temperature in the bathroom sink was observed to be 124 degrees Fahrenheit and the LPN
confirmed the temperature reading. The LPN also confirmed there were packages of disposable incontinent
care products opened and on the floor stored under the sink for resident use.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 17
Event ID:
365265
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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
Residents Affected - Some
During an observation of room [ROOM NUMBER] and interview with Licensed Practical Nurse #150 on
03/04/19 at 2:53 P.M. it was observed the water temperature in the bathroom sink was 124 degrees
Fahrenheit and there were opened packages of disposable incontinent care products on the floor under the
sink. LPN #150 verified the water temperature and stated the resident incontinent care products were kept
under the sink on the floor or on a shelf in the closet. Observation of the shelf revealed there was no space
available for the incontinent care products. The LPN stated the residents on this hall have a lot of equipment
and often the shelves have other items stored there.
The residents in Rooms #60, #65, #66 where not independently mobile.
Review of the Policy titled Housekeeping and Maintenance Services, section: Quality of Life, Policy Number
104.180, dated 5/2003 with a review date of February 2015 revealed the facility would provide
housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior.
Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping
residents' care requirement clean and properly stored. Comfortable interior means comfortable and safe
temperature level.
Review of Policy titled Hot/Cold water temperatures, section: Physical Environment, Policy Number
114.920, dated 06/14/17 revealed the facility's standard for water temperatures servicing resident and
visitor areas was 110 through 117 degrees Fahrenheit. Resident areas included resident bathrooms, visitor
bathrooms, activity rooms, therapy rooms, soda shops, beauty parlors, central bathing area, exam rooms,
dining rooms and employee break rooms.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 2 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #192's medical record revealed an admission date of 02/08/19. Medical diagnoses included
diabetes mellitus, chronic obstructive pulmonary disorder, bipolar disorder, chronic kidney disease,
cerebrovascular disease, malignant neoplasm of cervix, morbid obesity, and chronic pain.
Residents Affected - Few
Review of the resident's comprehensive admission Minimum Data Set (MDS) assessment dated [DATE]
revealed the resident had a brief interview for mental status (BIMS) score of 14, indicating minimal
cognitive impairment. The resident was at risk for pressure ulcers and had an unhealed unstageable deep
tissue injury pressure ulcer present on admission.
Review of the resident's nursing skin/wound note dated 02/14/19 revealed the resident saw the wound
physician. It was documented the right buttock had opened and was debrided. Measurements were 5.0
centimeters (cm) x 3.0 cm x 0.1 cm. The open area was noted to contain 90% granulation tissue and 10%
slough. A treatment of calcium alginate and cover with dry protective dressing daily was initiated. The area
was coded as an unstageable deep tissue injury.
Review of the wound physician's noted dated 02/14/19 revealed 1.5 cm of devitalized tissue including
slough biofilm, non-viable subcutaneous fat, and surrounding connective tissues at a depth of 0.1 cm was
debribed, and healthy bleeding tissue was observed. The area was coded as an unstageable deep tissue
injury.
Review of the National Pressure Ulcer Advisory Panel revealed a stage three pressure injury was defined
as full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole
(rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage
varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and
tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or
eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Interview with Registered Nurse/Wound Nurse #450 on 03/06/19 at 9:08 A.M. revealed the resident's right
buttock pressure ulcer should have been coded as a stage three pressure ulcer based on the description of
the wound on 02/14/19. She verified the wound was coded incorrectly as an unstageable deep tissue injury
on the resident's admission MDS assessment section M, dated 02/15/19.
Based on record review and facility staff interview the facility failed to code the minimum data set 3.0
(MDS)accurately for one (Resident #2) of one resident reviewed for hospice services and one (Resident
#192) one of four (#25, #48, and #73) reviewed for pressure ulcers. The total facility census was 104.
Findings Include:
1. Review of medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]
with diagnoses that included cerebral palsy, constipation, glaucoma, weakness, type two diabetes, cerebral
atherosclerosis, complete traumatic amputation at knee level left lower leg, contracture, depression,
unspecified intellectual disabilities, hypertension, cardiac arrhythmias, gastro-esophageal reflux disease,
osteoporosis, dysphagia, and osteoarthritis.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 3 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of medical record revealed the resident started receiving hospice services on 05/23/18 for
diagnosis of cerebral arteriosclerosis.
Review of most recent quarterly minimum data set (MDS) dated [DATE] revealed the resident was unable to
complete the brief interview of mental status, but had short and long term memory problems, had no
delusions or hallucinations but had verbal behaviors four to six days of the review period and other
behaviors one to three days of the review period. The resident was dependent on staff for activities of daily
living. The resident was always incontinent of bowel and bladder. The question J 1400 was coded no, the
question asking does the resident have a condition or chronic disease that may result in a life expectancy of
less than six months, The resident was coded as receiving hospice services under section O. Review of
past MDS assessments revealed J 1400 was coded no on:05/23/18, 08/23/18, and 02/08/19.
During an interview with MDS Registered Nurse #250 on 03/06/19 at 2:50 P.M. the RN stated there was no
signed physician documentation in the medical record regarding the resident having a life expectancy of
less than six months, or section J 1400 would have been coded as yes. Upon review of the RAI manual
coding instructions for section J 1400 with RN # 250 it was confirmed the MDS was coded incorrectly for
section J 1400.
Review of the Resident Assessment Instrument (RAI)3.0 manual revealed the minimum data set section J
1400 should be coded as yes if the medical record included physician documentation that the resident was
terminally ill; or the resident was receiving hospice services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 4 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to ensure a resident identified with a new serious
mental disorder was referred for a Level II Preadmission Screening and Resident Review (PASARR). This
affected one (Resident #48) of one resident's reviewed for PASARR. The facility census was 104.
Findings include:
Review of Resident #48's medical record revealed an admission date of 01/04/18. Medical diagnoses
included diverticulitis of large intestine with perforation and abscess, cognitive communication deficit,
chronic kidney disease, bipolar disorder, seizures, major depressive disorder, and anxiety.
Review of the resident's PASARR screen revealed the last one completed was dated 08/31/17. This was a
level one screen and did not include the resident's diagnoses of mental illness.
Review of the resident's medical diagnosis list revealed she was diagnosed with bipolar disorder on
05/19/18.
Review of the resident's mental health diagnostic assessment dated [DATE] revealed she was referred due
to anger problems of moderate severity, duration of less than six months. She had complaints of anxiety
and depression, which were significant. The resident was receiving counseling and psychotherapy two to
five times per month since 11/15/18.
Review of the resident's annual comprehensive Minimum Data Set (MDS) assessment dated [DATE]
revealed the resident was not considered by state level II PASARR process to have a serious mental illness
and/or intellectual disability. Review of the resident's diagnoses revealed they included bipolar disorder,
anxiety, and major depressive disorder.
Interview with Licensed Social Worker (LSW) #520 on 03/05/19 at 12:58 P.M. verified the resident was
diagnosed with bipolar disorder on 05/19/18. She verified the resident's PASARR level one screen dated
08/31/17 did not identify the resident as having a mental illness. She stated she had not submitted any
additional PASARRs for the resident after the diagnosis of bipolar disorder.
Further interview with LSW #520 on 03/06/19 at 10:12 A.M. revealed she found out she was supposed to
submit a new PASARR when the resident had a new psychiatric diagnosis in May 2018.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 5 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff and resident interviews, and review of a facility policy, the facility
failed to ensure a physician ordered preventative pressure ulcer intervention were included in a resident's
comprehensive care plan. This affected one (Resident #192) of four residents reviewed for pressure ulcers.
The facility identified 13 residents with pressure ulcers. The facility census was 104.
Findings include:
Review of Resident #192's medical record revealed an admission date of 02/08/19. Medical diagnoses
included diabetes mellitus, chronic obstructive pulmonary disorder, bipolar disorder, chronic kidney disease,
cerebrovascular disease, malignant neoplasm of cervix, morbid obesity, and chronic pain.
Review of the resident's comprehensive admission Minimum Data Set (MDS) assessment dated [DATE]
revealed the resident had a brief interview for mental status (BIMS) score of 14, indicating minimal
cognitive impairment. The resident was at risk for pressure ulcers and had an unhealed unstageable deep
tissue injury pressure ulcer to the right buttock present on admission. She had no behaviors and no
rejection of care. She required extensive assistance of two plus's staff for bed mobility, toilet use, and
personal hygiene. She was totally dependent for transfers.
Review of the resident's physician's orders revealed an order written on 02/07/19 for heel/ankle protectors.
Review of the resident's treatment administration record revealed the order was not included.
Review of the resident's comprehensive care plan created on 02/08/19 and revised on 02/12/19 revealed
the resident had pressure ulcers and was at risk for future pressure ulcer development. The goal was for
the resident to have intact skin, free of redness, blisters or discoloration. Interventions included
administering treatments as ordered and monitoring for effectiveness, educating the
resident/family/caregivers as to causes of skin breakdown, the importance of taking care during
ambulation/mobility, good nutrition, frequent repositioning, low air loss mattress to the bed,
monitor/document/report to physician any changes in skin status, pressure relieving/reducing device on bed
and chair, and to see the in house wound physician. The interventions did not include heel protectors or any
mention of off-loading heels.
Review of the resident's skin/wound notes dated 02/11/9, 02/14/19, 02/21/19, and 02/28/19 revealed outer
heels were red and blanchable and interventions were to include heel protectors for bilateral feet.
Observations of the resident in bed on 03/04/19 at 3:40 P.M., 03/05/19 at 9:37 A.M., 1:14 P.M., 3:23 P.M.,
and 4:42 P.M., and 03/06/19 at 8:55 A.M. revealed the resident was in bed with her heels on the mattress.
She did not have her heels elevated with pillows or any other offloading device.
Interview with Resident #192 on 03/04/19 at 3:40 P.M. revealed the resident was not aware she was to
wear any type of heel protective devices or keep her heels elevated off the mattress.
Interviews with State Tested Nursing Assistant (STNA) #470 and STNA #490 on 03/05/19 at 1:33 P.M.
revealed they were not aware of an order for boots or heel protectors to offload the resident's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 6 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0656
heels.
Level of Harm - Minimal harm
or potential for actual harm
Interview with Licensed Practical Nurse (LPN) #600 on 03/06/19 at 8:55 A.M. verified the resident was in
bed with her heels resting on the bed and not offloaded.
Residents Affected - Few
Interview with Registered Nurse/Wound Nurse #450 on 03/06/19 at 9:08 A.M. revealed the resident should
have been wearing heel protectors as her heels had been red since admission. She verified the resident
had an order for heel/ankle protectors. She stated this was a type of cushion with a strap to protect the
resident's heels from pressure. She verified the resident's care plan did not contain the intervention of heel
protectors. She verified there were not heel protectors in the resident's room and the resident's heels
remained red.
Review of a facility policy titled Pressure Ulcer Policy revised on 04/29/16 revealed appropriate preventative
interventions will be implemented. (i.e. wheelchair cushion, offloading heels, etc.). A resident with a
pressure ulcer will receive interventions and monitoring to promote healing, prevent infection and prevent
new ulcers from developing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 7 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, medical record review, resident and staff interview and review of contingency box, the facility
failed to ensure a resident's skin condition was monitored. This affected one (Resident #25) of two residents
reviewed for skin conditions. The facility census was 104.
Residents Affected - Few
Findings include:
Review of Resident #25's medical record revealed an admission date of 02/23/13. Medical diagnoses
included paraplegia, cognitive communication deficit, anxiety, chronic kidney disease, diabetes mellitus,
morbid obesity, peripheral vascular disease, and neurogenic bowel.
Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed no impairment in
cognition. The resident had no behaviors and no rejection of care. He required extensive assistance with
two plus staff for bed mobility and transfers. The resident was identified as at risk for pressure ulcer
development. He was identified as having surgical wounds. He received surgical wound care. Review of the
resident's comprehensive MDS dated [DATE] revealed a care area assessment (CAA) for skin. The CAA
identified the resident was at risk for skin impairment due to needing assistance with bed mobility, transfers
per hoyer lift, non-ambulatory, incontinence of bowel, obesity, and had areas of shearing with treatment in
place.
Review of the resident's physician's orders revealed an order dated 12/21/18 for a treatment to areas of
shearing on bilateral buttocks; cleanse with soap and water, pat dry, apply alginate cut to size secure with
optifoam sacral, one to each buttock every evening and as needed.
Review of the resident's treatment administration record for February and March revealed the treatment
had been signed off daily. It was also signed off as needed nine times in February and two times in March.
Review of the resident's care plan revealed the care plan was last revised on 03/05/19. The resident was at
risk for skin breakdown related to impaired mobility, obesity, use of psychotropics, history of breakdown,
loss of sensation of bilateral lower extremities, suprapubic catheter, excoriated buttocks, history of post
surgical area to buttocks, and refusal to turn from side to side for prevention. Interventions included
treatment to buttocks as ordered and monitor effectiveness and weekly skin assessment.
Review of the resident's nursing notes 02/01/19 through 03/06/19 revealed no mention of the shearing to
the buttocks and no description or monitoring of the wounds.
Review of the resident's weekly skin and body review assessments from 02/10/19 through 03/03/19
revealed on 02/10/19, documentation indicated no change on all sheared area noted. On 02/17/19,
documentation indicated sheared areas continue to bilateral buttocks. On 02/24/19, documentation
indicated no new areas noted. Shearing remains to buttocks with bleeding during treatment. Resident will
not turn side to side, continues to lie on back. Will help pull self up in bed. On 03/03/19, documentation
indicated no new areas noted. Nothing was documented regarding the sheared areas to the resident's
buttocks.
Observation of wound care on 03/06/19 at 3:30 P.M. with Registered Nurse (RN) Wound Nurse #450
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 8 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
revealed the resident had numerous open areas to the lower buttock/upper thigh region bilaterally, and the
scrotum. All open areas were bright red and some areas were bleeding. Old scar tissue was noted across
both buttocks. The resident stated he had a surgical repair of a pressure area years ago. RN #450 stated
she was not following the resident as he was not being seen by the wound physician. She stated she was
not aware the shearing was so bad and the nursing staff should have notified her so he could be followed
by the wound physician. She stated she thought the open areas were all from shearing.
Review of RN #450's skin/wound noted dated 03/06/19 at 3:30 P.M. revealed areas to old surgical areas to
bilateral buttocks were shear. Area to inferior scrotum was also noted to be shearing and measured 0.5
centimeters (cm) x 2.5 cm x 0.1 cm. From this assessment, physician was contacted and order was
received for resident to be seen by in house wound doctor for evaluation and treatment.
Interview with the Director of Nursing on 03/07/19 at 8:40 A.M., verified there was no documentation of skin
monitoring of the resident's sheared areas to his bilateral buttocks or scrotum documented on 03/03/19.
She also verified the last nursing weekly assessment of the resident's wound was on 02/24/19, however no
measurements or descriptions of the shearing were noted. She stated the facility did not have a policy
regarding skin monitoring.
Interview with RN #450 on 03/07/19 at 10:53 A.M. revealed the wound physician saw the resident on
03/07/19. He continued the calcium alginate treatment, but changed the foam dressing to an ABD dressing.
Interview with Physician #500 on 03/07/19 at 1:23 P.M. revealed she assessed the resident's open areas on
03/07/19. She stated all areas were shearing and were over the old surgical areas. She stated nothing
looked deeper than what a stage two pressure ulcer would present as.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 9 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff and resident interviews and review of a facility policy, the facility
failed to ensure a physician ordered preventative pressure ulcer intervention was implemented for a
resident with a pressure ulcer. This affected one (Resident #192) of four residents reviewed for pressure
ulcers. The facility identified 13 residents with pressure ulcers. The facility census was 104.
Residents Affected - Few
Findings include:
Review of Resident #192's medical record revealed an admission date of 02/08/19. Medical diagnoses
included diabetes mellitus, chronic obstructive pulmonary disorder, bipolar disorder, chronic kidney disease,
cerebrovascular disease, malignant neoplasm of cervix, morbid obesity, and chronic pain.
Review of the resident's physician's orders revealed an order written on 02/07/19 for heel/ankle protectors.
Review of the resident's treatment administration record revealed the order was not included.
Review of the resident's comprehensive care plan created on 02/08/19 and revised on 02/12/19 revealed
the resident had pressure ulcers and was at risk for future pressure ulcer development. The goal was for
the resident to have intact skin, free of redness, blisters or discoloration. Interventions included
administering treatments as ordered and monitoring for effectiveness, educating the
resident/family/caregivers as to causes of skin breakdown, the importance of taking care during
ambulation/mobility, good nutrition, frequent repositioning, low air loss mattress to the bed,
monitor/document/report to physician any changes in skin status, pressure relieving/reducing device on bed
and chair, and to see the in house wound physician. The interventions did not include heel protectors or any
mention of off-loading heels.
Review of the resident's comprehensive admission Minimum Data Set (MDS) assessment dated [DATE]
revealed the resident had a brief interview for mental status (BIMS) score of 14, indicating minimal
cognitive impairment. The resident was at risk for pressure ulcers and had an unhealed unstageable deep
tissue injury pressure ulcer to the right buttock present on admission. She had no behaviors and no
rejection of care. She required extensive assistance of two plus's staff for bed mobility, toilet use, and
personal hygiene. She was totally dependent for transfers.
Review of the resident's skin/wound notes dated 02/11/9, 02/14/19, 02/21/19, and 02/28/19 revealed outer
heels were red and blanchable and interventions were to include heel protectors for bilateral feet.
Review of a skin/wound note dated 03/06/19 revealed the resident's right buttock was now being coded as
stage three pressure ulcer per the physician's notes. The note also indicated the resident's admission MDS
dated [DATE] was updated to reflect a stage three pressure ulcer.
Observations of the resident in bed on 03/04/19 at 3:40 P.M., 03/05/19 at 9:37 A.M., 1:14 P.M., 3:23 P.M.,
and 4:42 P.M., and 03/06/19 at 8:55 A.M. revealed the resident was in bed with her heels on the mattress.
She did not have her heels elevated with pillows or any other offloading device.
Interview with Resident #192 on 03/04/19 at 3:40 P.M. revealed the resident was not aware she was to
wear any type of heel protective devices or keep her heels elevated off the mattress.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 10 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0686
Level of Harm - Minimal harm
or potential for actual harm
Interviews with STNA #470 and STNA #490 on 03/05/19 at 1:33 P.M. revealed they were not aware of an
order for boots or heel protectors to offload the resident's heels.
Interview with Licensed Practical Nurse (LPN) #600 on 03/06/19 at 8:55 A.M. verified the resident was in
bed with her heels resting on the bed and not offloaded.
Residents Affected - Few
Interview with Registered Nurse/Wound Nurse #450 on 03/06/19 at 9:08 A.M. revealed the resident should
have been wearing heel protectors as her heels had been red since admission. She verified the resident
had an order for heel/ankle protectors. She stated this was a type of cushion with a strap to protect the
resident's heels from pressure. She verified the resident's care plan did not contain the intervention of heel
protectors. She verified there were not heel protectors in the resident's room and the resident's heels
remained red.
Review of a facility policy titled Pressure Ulcer Policy revised on 04/29/16 revealed appropriate preventative
interventions will be implemented. (i.e. wheelchair cushion, offloading heels, etc.). A resident with a
pressure ulcer will receive interventions and monitoring to promote healing, prevent infection and prevent
new ulcers from developing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 11 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, medical record review, staff interview and review of contingency box, the facility failed to
timely initiate a resident's antibiotic therapy. This affected one (Resident #56) of two residents reviewed for
respiratory care. The facility census was 104.
Finding include:
Review of Resident #56's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses that included chronic respiratory failure, unspecified whether with hypoxia or hypercapnia,
muscular dystrophy, gastro esophageal reflux disease, obstructive and reflux uropathy, depressive disorder,
anemia, dependence on respirator, anxiety, dysphagia, gastrostomy, contracture of multiple sites, cachexia,
pressure ulcer, and moderate protein calorie malnutrition.
Review of the most recent quarterly minimum data set (MDS) dated [DATE] revealed the resident had a
brief interview of mental status score of 15 indicting the resident was cognitively intact, had no delusions,
hallucinations or behaviors, was dependent on staff for daily cares, resident was always incontinent of
bowel, and had a urinary catheter. Resident #56 had functional limitations in all four extremities without
prosthesis. The resident was coded for his oxygen, suctioning, tracheostomy, and invasive mechanical
ventilator.
Review of progress note by Certified Nurse Practitioner #600 on 10/29/18 to start Levaquin 750 milligram
(mg) per G Tube daily for seven days.
Review of Resident #56's October 2018 medication administration record revealed the resident was not
started on Levaquin (Antibiotic) 750 mg until 10/30/18.
Review of the contingency box (box of medications the facility had on stock to fill new orders received so
there was no wait from pharmacy to initiate the first doses of a newly ordered medication or to use with new
admit residents. ) list revealed the box contains four Levaquin 500 mg and four Levaquin 250 mg tablets.
During an interview with Licensed Practical Nurse #350 on 03/06/19 at 10:25 A.M. it was revealed if a
resident received a new order for an antibiotic the medication should be given as soon as possible. The
nurse stated she would review the contingency box list to see if the medication was available in the box and
use it from there and if the medication was not available from the contingency box she would have the
medication dropped shipped from the pharmacy and stated if that occurred it would arrive in approximately
four hours.
During an interview with the Director of Nursing on 03/06/19 at 11:10 A.M. it was confirmed #56 had orders
for an antibiotic written on 10/29/18 and the medication was not initiated until 10/30/18. The antibiotic
ordered was confirmed to be available in the contingency box and should have been started at the time the
order was received.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 12 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and facility staff interview the facility failed to ensure residents did not receive excessive
doses of medication. This affected one (Resident #90) of six reviewed for un-necessary. The total facility
census was 104.
Residents Affected - Few
Findings include:
Review of Resident #90's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses that include but are not limited to chronic diastolic heart failure, hypertensive heart disease,
cellulitis of left lower limb, contusion of right knee, cognitive communication deficit, specified disorders of
bone density and structure unspecified, history of falls, hyperlipidemia, age related osteoporosis,
abnormalities, syncope Alzheimer's disease, hypertension, rheumatic mitral valve disease, on rheumatic
aortic insufficiency, and idiopathic gout.
Review of the most recent quarterly Minimum Data Set, dated [DATE] revealed the resident has a brief
interview of mental status score of 7 indicating the resident has cognitive impairment, the resident had no
delusions, hallucinations or behaviors during the review period. the resident requires extensive assist for
hygiene, and toileting, limited assist for bed mobility transfers and supervision for eating and locomotion on
and off the unit. The resident is occasionally incontinent of urine and always continent of bowel.
Review of progress notes revealed the resident on 02/26/19 expressed concern that her lower extremity
was swollen and discolored and slightly warm to touch the physician was updated and new order for
Augmentin for seven days for possible cellulitis.
Review of resident physician orders revealed the resident had orders for Augmentin tablet 875-125 MG
(antibiotic) one by mouth two times a day for cellulitis for 13 administrations until finished. The medication
order was written on 02/26/19.
Review of the February medication administration record revealed the resident had the Augmentin started
on 02/26/19 with the evening dose. The resident received two doses on subsequent days through February.
Review of the March 2019 Medication Administration Record revealed the resident received two doses a
day through 03/05/19 indicating the resident received a total of 15 doses and not the 13 doses on the order.
Review of care plans revealed the resident had a care plan for the use of antibiotic for cellulitis and the
antibiotic is in use from 02/27/19-03/05/19.
During an interview with Licensed Practical Nurse (LPN) #350 on 03/06/19 at 10:25 A.M. it was confirmed
the resident received 10 doses of Augmentin in March and 5 doses in February for a total for 15 doses. The
nurse verified the order stated one tab two times a day for 13 administrations, LPN #350 stated the resident
received unnecessary doses that were not ordered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 13 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review if
the facility risk assessment dated [DATE] documented the facility should have a water management
program for the hot and cold water distribution to reduce the risk of Legionella growth and spread. These
points of possible Legionella growth were documented to have chlorine testing completed on a quarterly
basis.
Residents Affected - Many
Review of Form A-0010 documented on 04/18/18 and 02/12/19 all areas assessed as a risk were not being
monitored as required per the facilities Appendix B Legionella management plan for control and prevention.
Further review documented chlorine testing was being completed but did not specify where the the testing
was being conducted. Appendix B of the legionella program documented to test chlorine levels quarterly at
the cold distribution at central shower/circulation tub and the hot distribution at the kitchen appliances and
central shower/circulation tub.
.
On 03/07/19 at 1:04 P.M., interview with Environmental Service Supervisor #610 verified he was not doing
the monitoring as it was required per the facilities risk assessment and policy. He verified he was only
monitoring the entry point to the building and at the end point in the building for chorine testing on a
quarterly. He further verified he was not aware he should have been conducting quarterly chlorine
monitoring at all the points indicated on Appendix B as required per the facility assessment and policy.
Review of Legionella policy-environmental dated 01/22/18 documented the facility would implement control
measures to reduce the potential growth and spreading of Legionella. Further review documented Appendix
B Legionella management plan for control and prevention dated 01/16/18 documented and identified the
control measures that included quarterly testing for chlorine levels at the cold distribution for central
shower/circulation tub and the hot distribution chlorine levels kitchen of the kitchen appliances and central
shower/circulation tub. In addition the policy identified to document the chlorine testing on form A-0010.
2. During an observation of the laundry room with Laundry Staff (LS) #300 on 03/06/19 at 4:10 P.M.,
revealed on a shelf on the dirty side of the laundry were six small pillows, a pair of soft heel off loading
boots, a pair of non skid slippers and one abdominal binder. Under the shelf was a rolling laundry hamper.
When asked what the items on the shelf were, LS #300 stated the items were unable to be placed in the
dryer and were on the shelf drying. The laundry worker stated the facility has always used the shelf to air
dry clean items that could not be placed in they dryer. After LS #300 stated it does not make sense to have
them drying on the dirty side of the laundry but space was an issue and that was where there were put to
dry.
During an interview with the administrator on 03/07/19 at 7:45 A.M., it was revealed the facility does not
have a specific policy regarding the storage of laundry. The administrator confirmed clean items should not
be in the dirty area of the laundry room.
Review of the Laundry Services E-3 audit tool dated May 2000 revealed clean linen was to be separated
from dirty linen.Based on medical record review, observation, staff interview, review of the facility's
legionella prevention plan, and review of facility documents, the facility failed to maintain infection control
measures when a nurse touched a resident's medications with bare hands and did not wear gloves when
checking a resident's blood glucose. This affected one Resident (#293) of six
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 14 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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
residents observed during medication administration. The facility also failed to separate clean and dirty
laundry in the laundry room and failed to implement their legionella prevention control plan. These both had
the potential to affect all 104 residents residing in the facility. The census was 104.
Findings include:
Residents Affected - Many
1. Review of Resident #293's medical record revealed an admission date of 03/01/19. Diagnoses included
spinal stenosis, chronic gout, diabetes mellitus, hypertension, and hypothyroidism.
Observation of Resident #293's finger stick blood sugar (FSBS) check on 03/06/19 at 7:28 A.M., revealed
licensed practical nurse (LPN) #150 was not wearing gloves. LPN #150 used a lancet and pierced the
finger of Resident #293. LPN #150 then squeezed the finger of Resident #293 and obtained a blood
sample to use for the blood glucose meter.
During an interview on 03/06/19 at 7:30 A.M. confirmed that she had not worn gloves while checking
Resident #293's FSBS.
Observation of the medication administration for Resident #293 on 03/06/19 at 7:35 A.M. revealed LPN
#150 opened six individually wrapped pill packets. LPN #150 opened each packet, pulled pill from packet
with bare hands, and placed them in a medication cup.
During an interview on 03/06/19 at 7:39 A.M. LPN #150 confirmed she touched Resident #293's
medications. LPN #150 proceeded to administer the medications to Resident #293.
Review of a facility document titled Skills Demonstration/Evaluations-Blood Glucose Testing dated January
2017 revealed that when performing blood glucose testing, staff were to cleanse hands with soap and water
or hand sanitizer and applies gloves.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 15 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, staff interview and review of antibiotic stewardship program policy, the
facility failed to ensure all antibiotics were assessed and reviewed as required through the facility antibiotic
stewardship program to ensure appropriate usage. This affected one (Resident #42) of six residents
reviewed for antibiotic use. The facility census was 104.
Residents Affected - Few
Findings include:
Review of medical record for Resident #42 documented an admission date of of 06/11/18 with diagnoses
including cerebral palsy, chronic obstructive pulmonary disease (COPD), muscle weakness, chronic
multifocal osteomyelitis, neuromuscular dysfunction of the bladder, diabetes type two, paraplegia, Spina
Bifida with hydrocephalus, dementia with behavioral disturbances, complications with skin grafts/ surgical
wounds and major depression.
Review of Resident #42's hospital record review dated 12/19/17 documented Resident #42 was sent back
to the facility with an order to for minocycline (Antibiotic) 50 milligrams (mg) every day by mouth for skin and
skin stricture infection. During this hospital admission she had no documentation of a communicable
disease just a history of vancomycin-resistant enterococci (VRE).
Review of Resident #42 entire medical record lacked an justification for the continue use of the minocycline.
Further review of the record lacked any physician review for justification of the use or any culture performed
to document Resident #42 had an active infection.
Review of infection control log dated 12/23/17 documented Resident #42 was receiving minocycline due to
methicillin resistant staphylococcus aureus (MRSA). Further review lacked any documentation of a positive
culture or documentation the medication was reviewed as part of the antibiotic stewardship program to
ensure appropriate usage.
Review of the physician order dated 12/29/17 documented Resident #42 had an order for minocycline 50
mg was to be given by mouth every day prophylactically.
Interview on 03/06/19 at 10:09 A.M., with Licensed Practical Nurse (LPN) #400 verified she never reviewed
the use of Resident #68's antibiotic use as part of the antibiotic stewardship program. She verified the
resident had been on it since 2017 and it was for the MRSA in her wounds. She then revealed she was not
sure if it meets the McGreers criteria since it was never reviewed. She also verified it should have been
reviewed for its continued use with appropriate physician documentation for it continued use.
Interview on 03/07/19 at 2:29 P.M., with LPN #400 verified there were no other cultures of Resident #42
wounds or physician progress note reviewing the use of the antibiotic use since 2016. During the 2016
hospital admission when she was positive for MRSA but was receiving intravenous antibiotics at that time
which was not the minocycline started in December 2017 during a hospital admission.
Review of policy titled antibiotic stewardship dated 10/17/17 documented the facility staff including work in
collaboration to prevent the unnecessary use of antibiotics. Further review documented care community
would review antibiotic appropriateness and suggest alternatives in consideration with the physician and
the pharmacist review.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 16 of 17
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
365265
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Piqua Manor
1840 West High Street
Piqua, OH 45356
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, policy review and facility staff interview, the facility failed to administer the influenza
vaccination to one (#54) of five (#17, #37, #56, and #90) reviewed for influenza vaccinations. The facility
census was 104.
Residents Affected - Few
Findings include:
Review of Resident #54's medical record revealed the resident was admitted to the facility on [DATE], with
diagnoses including metabolic encephalopathy, indeterminate colitis, cognitive decline, urinary tract
infection, acute kidney failure, gastro esophageal reflux disease, hypertensive heart disease, benign
prostatic hypertension, symbolic dysfunctions, unspecified hearing loss, insomnia, and anxiety.
Review of progress notes dated 01/03/19 at 1:04 P.M., indicated the resident approached the nurse and
asked when he was going to get his flu vaccine. The nurse explained that according to his record, the
resident refused. The progress note further indicated they would update the physician later for the residents
request.
Review of medical record revealed Resident #54 signed a consent to receive a influenza vaccine on
01/08/19. The medical record was silent to the resident receiving the vaccination.
Review of the most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed the
resident had a brief interview of mental status (BIMS) score of 14 indicating the resident was cognitively
intact. The resident was able to understand others and make self understood. The influenza vaccination
was coded a refused.
Review of his medication administration record for January, February and March 2019 revealed the records
were silent to the resident receiving the influenza vaccine.
Interview on 03/06/18 at 3:21 P.M., with Licensed Practical Nurse (LPN) #400 confirmed Resident #54 had
no evidence supporting the resident had received his influenza vaccination at the facility, after the resident
signed the consent to receive the vaccination on 01/08/19.
Review of the Resident influenza (FLU) vaccination policy dated July 2003 and revised October 2016
revealed it was the policy of the facility with the advice of the Medical Director that all residents would be
offered the influenza vaccination unless contraindicated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365265
If continuation sheet
Page 17 of 17
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
FAQ · About this visit
Common questions about this visit
What happened during the March 7, 2019 survey of PIQUA MANOR?
This was a inspection survey of PIQUA MANOR on March 7, 2019. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PIQUA MANOR on March 7, 2019?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.