Inspection·February 26, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, interviews, and policy review, the facility failed to ensure showers were provided as scheduled. This affected three (Residents #89, #72 #85) of three residents reviewed for bathing. The facility census was 94. Residents Affected - Few Findings include: 1. Medical record review for Resident #89 revealed an admission date of 02/12/24 with diagnoses including but not limited to stroke, diabetes mellitus type two, carpel tunnel bilateral upper extremities, hypertension and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the assessment was not completed at the time of the survey. Review of the plan of care for Resident #89 dated 02/23/24 revealed Resident #89 had an activities of daily living (ADL) self care performance deficit related to hypertension, stroke, diabetes, and cognitive impairment. Interventions included resident requires one staff participation with bathing, supervision with transfers and encouragement to use call bell for assistance. Observation and interview on 02/22/24 at 4:14 P.M. of Resident #89 stated he could not remember when his last shower was provided. Further stated unable to recall what day his showers were scheduled. Review of the response history documentation for Resident #89 dated 02/12/24 through 02/26/24 revealed no showers were documented as given for Resident #89. Interview on 02/27/24 at 2:19 P.M. with Corporate Registered Nurse (RN) #350 verified the facility did not have any additional documentation to indicate showers were provided for Resident #89. Further verified showers should have been completed two times a week. 2. Medical record review for Resident #72 revealed an admission date of 01/30/24 with diagnoses including but not limited to iron deficiency anemia, arteriovenous malformation of cerebral vessels, hypertension, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the assessment was not completed at the time of the survey. Review of the plan of care for Resident #72 dated 2/12/24 revealed the resident had an ADL care (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 4 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 02/26/2024 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)