Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Piqua Manor during CMS and state inspections, most recent first.
Improper refrigerator temperature control was observed in the kitchen when three storage refrigerators were found above the required range, with internal temperatures of 46 to 50 degrees F. An NSA also removed pudding and milk from the refrigerators and both foods measured 45 degrees F. A facility policy stated refrigerator temperatures should be 41 degrees F or below.
Two residents experienced changes in condition for which staff did not notify the attending physicians as required by orders, care plans, and facility policy. One resident with COPD and continuous O2 use had nighttime breathing difficulties and was later sent to the hospital at family request, but staff did not document vital signs, assessments, or any physician notification regarding the respiratory change or the transfer. Another resident with CHF, diabetes, and chronic kidney disease had multiple documented daily weight gains exceeding the physician-ordered threshold for notification, yet there was no record that the physician was informed of these weight changes.
A resident’s urinal, containing 1000 mls of urine, was routinely placed on the bedside tray table used for meals and personal items, alongside the resident’s medication and belongings. The resident said they did not like the urinal being kept there and reported there was no other place to put it. A CNA and RN both verified the routine placement for accessibility, and no alternative storage or designated area was available within the resident’s reach.
Inconsistent Code Status Documentation: A resident with multiple chronic conditions and moderately impaired cognition had conflicting code status documentation across the chart. The EHR showed a DNRCC-A order, while the paper record listed the resident as full code and no state DNR form was found; the care plan also listed DNRCC-A. An LPN confirmed the mismatch between the paper record and EHR.
Failure to Investigate Trauma-Related Wound: A resident with severe cognitive impairment, dementia, and malnutrition developed a full-thickness right hip wound documented by the NP as trauma-related and in-house acquired while staff were getting the resident up for a shower. The DON and RCN confirmed there was no investigation and no documentation of the wound’s origin, despite the facility policy requiring accidents and incidents to be investigated and reported.
A resident’s chlorhexidine mouth/throat solution was left in a medication cup on the bedside tray and was readily accessible instead of being administered. The resident had no self-administration assessment on file, and an RN verified the medication should have been administered rather than left on the table. The RCN confirmed the resident was not able to self-administer medications.
A resident with COPD and oxygen therapy had a respiratory change in condition and was later sent to the hospital per family request, but the medical record did not include the reason for transfer, vital signs, or assessments. The DON confirmed the resident had trouble breathing overnight, and an LPN stated she obtained vital signs after report of breathing difficulty but did not document the resident’s condition or the vital signs; the DON also stated an SBAR assessment should have been completed.
Failure to use gowns during EBP high-contact care: Staff did not wear gowns while providing wound care to one resident and tracheostomy care to another resident, even though EBP signs were posted above both beds. The residents had significant medical needs, including open skin lesions, severe cognitive impairment, and tracheostomy/ventilator dependence, and the facility policy required impervious gowns for wound care and tracheostomy/ventilator care.
Failure to document and provide flu and pneumococcal vaccinations affected 3 of 5 residents reviewed. One cognitively intact resident with MS, DM2, CHF, depression, and sleep apnea had no record of being offered or receiving a pneumococcal vaccine. A resident with dementia and severely impaired cognition had a family-signed pneumococcal consent, but no record of the vaccine being offered or administered and no documentation of prior vaccine type or date. Another cognitively intact resident with AFib, liver failure, anxiety, depression, and kidney failure consented to flu vaccine, but the MAR showed it as held without a documented reason and no record of administration.
A resident with severe cognitive impairment was allegedly photographed by a CNA while topless in her room. The incident was witnessed and reported to the Administrator, but the facility failed to notify the Ohio Department of Health as required by policy, and not all witnesses were interviewed during the internal investigation.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with severe cognitive impairment, after a CNA was reported to have taken a photo of the resident while she was topless. Although some staff and the accused CNA were interviewed, two CNAs in training who were present were not interviewed, and there was no documentation of interviews with other residents or notification to the state health department as required by policy.
Improper Refrigerator Temperature Control
Penalty
Summary
The facility failed to store food in a safe manner. During an initial kitchen tour, three storage refrigerators were observed outside the temperature range needed to prevent food-borne illnesses: refrigerator #1 read 50 degrees F, refrigerator #2 read 46 degrees F, and refrigerator #3 read 50 degrees F on their internal thermometers. During the same observation, NSA #48 obtained pudding from refrigerator #1 and the pudding measured 45 degrees F, and milk from refrigerator #3 measured 45 degrees F; NSA #48 confirmed the refrigerator and food temperatures. The facility identified four residents (#12, #38, #85, and #98) who received nothing by mouth, and the census was 87. A policy titled Infection Control/Food Safety Storage of Perishable Foods, dated 01/2026, stated that a reliable thermometer shall be provided in each refrigerator and freezer and that refrigerator temperatures should be 41 degrees or below.
Failure to Notify Physicians of Resident Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians of residents’ changes in condition in a timely manner, as required by physician orders, care plans, and facility policy. For one resident with centrilobular emphysema, COPD, and essential hypertension who used continuous oxygen at three liters via nasal cannula, the care plan directed staff to monitor for and report signs of respiratory distress to the physician. On one occasion, the resident experienced trouble breathing during the night and initially refused transfer to the hospital. The DON recalled this event and stated that the resident’s daughter later convinced the resident to go to the hospital that morning. However, the medical record contained no documentation of vital signs, assessments, or any notification to the physician regarding the change in respiratory status or the subsequent hospitalization, and the DON confirmed the assigned LPN did not document the change in condition or physician notification. For a second resident admitted with diagnoses including disruption of an external surgical wound, infection following a procedure, combined systolic and diastolic CHF, type 2 diabetes with polyneuropathy, and chronic kidney disease, the care plan required monitoring and reporting to the physician of significant weight changes and changes in lung sounds, edema, shortness of breath, vital signs, and weight. A physician order directed staff to notify the physician of a weight gain of two or more pounds in one day or five pounds in one week. Weight records showed the resident gained 4.0 lbs from one day to the next on one occasion and 3.4 lbs from one day to the next on another occasion. There was no documentation in the medical record that the physician was notified of these weight gains, and the regional clinical nurse confirmed that the physician was not notified on those dates, contrary to the physician’s order and facility policy requiring notification of changes affecting the resident.
Failure to Reasonably Accommodate Urinal Placement
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences related to the placement and use of a urinal in the resident’s room. During observation, a urinal containing 1000 mls of urine was placed on the bedside tray table, the same surface used for meals and personal items, and the resident’s medication and personal items were also on the tray at that time. The resident stated the urinal being placed on the bedside table was not liked and reported there was no other place to put it. Observation during the interview showed no alternative storage or designated area available within the resident’s reach. A CNA verified the urinal was routinely placed on the bedside tray for accessibility and acknowledged the resident had expressed concerns, but no changes were made. An RN also verified the routine placement of the urinal on the bedside tray and discussed placing snacks in a basket on the tray with the urinal on the bedside table with no other items.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure Resident #103’s code status was consistent throughout the medical record. The resident was admitted with diagnoses including urinary tract infection, hypertensive chronic kidney disease, type II diabetes, unspecified dementia, atrial fibrillation, and peripheral vascular disease. The MDS assessment showed the resident’s cognitive status was moderately impaired. In the EHR, there was a physician order for DNRCC-A, meaning CPR would be provided until heart or breathing stopped and comfort care measures would then be implemented. In the paper medical record, a document dated [DATE] identified the resident as full code, and no state DNR form was found in the paper record. The plan of care identified the resident with a code status of DNRCC-A. An LPN confirmed that the code status order in the paper medical record did not match the code status order in the EHR and stated she would confirm with the physician and family which code status was correct. The facility’s advance directives policy stated advance directives would be reviewed with the resident and/or responsible party upon admission.
Failure to Investigate Trauma-Related Wound
Penalty
Summary
The facility failed to investigate a resident's skin condition that was documented as trauma-related and in-house acquired. Resident #38 was admitted with diagnoses including malnutrition, psychotic disturbance, hearing loss, and dementia, and an annual MDS assessment showed severely impaired cognition, no pressure sores, and open skin lesions. Progress notes documented an open area on the right hip, and the resident was later added to the NP's weekly wound rounds. NP wound notes identified the right hip wound as a full-thickness wound related to trauma and documented that it was reportedly obtained while staff were getting the resident up for a shower. The wound remained documented as in-house acquired and trauma-related on later NP wound notes, with the wound increasing in size and depth over time. During interview, the DON and RCN confirmed the right hip wound was documented as the result of trauma and acknowledged that no investigation had been completed and there was no documentation of the origin of the wound. The facility policy stated that all accidents and incidents involving residents or staff must be investigated and reported to the Administrator or designee.
Unsafe Medication Storage and Administration
Penalty
Summary
Medications were not maintained in a safe and secure manner for one resident observed for medication storage. Resident #71 had an order for chlorhexidine gluconate mouth/throat solution 0.12% to be given by mouth twice daily with instructions to spit it out and not swallow. The medical record did not show a self-administration assessment for the resident. During observation, a medication cup containing a light blue liquid substance was left on the bedside tray and was readily accessible. The resident stated that medications were typically brought in and left on the bedside tray for him to take, and he said he had already taken his pills but had not completed the mouthwash. An RN verified that the medication at the bedside was chlorhexidine gluconate mouth/throat solution 0.12% and stated it should have been administered instead of left on the table. The RCN confirmed that no self-administration assessment had been completed because the resident was not able to self-administer medication.
Incomplete Documentation of Resident’s Respiratory Change in Condition
Penalty
Summary
The facility failed to ensure the medical record was complete and accurate related to a resident’s change in condition. Resident #106 was admitted on 07/19/24 with diagnoses including centrilobular emphysema, COPD, and essential hypertension, and the care plan identified oxygen therapy for COPD with monitoring for respiratory distress. The record showed the resident was cognitively intact and required varying levels of assistance with activities of daily living. A notification note dated 01/02/26 at 9:39 A.M. documented that the resident was sent to the hospital per family request. Further review found no documented specifics about the reason for hospitalization, including no vital signs or resident assessments. The DON stated Resident #106 had trouble breathing during the night but initially refused hospital transfer, and later the resident’s daughter convinced the resident to go to the hospital. The DON confirmed the night nurse did not document the resident’s respiratory change, vital signs, or assessments, and stated the expectation was to document all changes in condition and notify the physician and family. The LPN confirmed she obtained vital signs after receiving report that the resident had been struggling to breathe, but did not document the resident’s condition or the vital signs in the medical record. The DON also stated the LPN should have completed an SBAR assessment when there was a change in condition or transfer to the hospital.
Failure to Use Gowns During EBP High-Contact Care
Penalty
Summary
The facility failed to ensure staff wore appropriate personal protective equipment during high-contact care for residents in enhanced barrier precautions (EBP). During observation, the Assistant Director of Nursing did not put on a gown before performing wound treatment on a resident with malnutrition, psychotic disturbance, hearing loss, dementia, and open skin lesions. A sign posted above the resident’s bed directed staff to use EBP for high-contact activities, including wound care, and the ADON later confirmed she had not worn a gown and that the resident was in EBP. The facility also failed to ensure a Respiratory Therapist wore a gown before providing tracheostomy care to another resident with muscle weakness, chronic hepatitis, malnutrition, severe cognitive impairment, tracheostomy care needs, and invasive mechanical ventilator dependence. A sign above that resident’s bed directed staff to use EBP for high-contact activities, including tracheostomy/ventilator care. The RT later confirmed she had not worn a gown and that the resident was in EBP. The facility policy stated that EBP requires targeted gown and glove use during high-contact resident care activities, including wound care and tracheostomy/ventilator care.
Failure to Document and Provide Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure influenza and pneumococcal vaccinations were offered and administered to residents, affecting 3 of 5 residents reviewed for immunizations. Resident #7 was admitted with diagnoses including multiple sclerosis, sleep apnea, type 2 diabetes mellitus, depression, and congestive heart failure, and was cognitively intact. Review of the resident’s immunization record showed no documentation that a pneumococcal vaccine was offered or administered, and no documentation that the resident had previously received a pneumococcal vaccine. Resident #38 was admitted with diagnoses including malnutrition, psychotic disturbance, hearing loss, and dementia, and had severely impaired cognition. Her son signed a pneumococcal vaccine consent document stating she had previously received the vaccine, but the immunization list contained no documentation that the vaccine was offered or administered at the facility, and there was no documentation of when or what type of pneumococcal vaccine had been received. Resident #70 was admitted with diagnoses including atrial fibrillation, liver failure, depressive disorder, anxiety disorder, and kidney failure, and was cognitively intact. The resident signed consent for influenza vaccination, but the MAR documented the vaccine as held with a note to see nursing notes, and the nursing notes did not document a reason; the immunization list also had no documentation that the influenza vaccine was administered.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with severe cognitive impairment and multiple medical diagnoses, including senile degeneration of the brain, hypertension, diabetes mellitus, and unspecified psychosis. The incident involved a staff member allegedly taking a photo of the resident while she was topless in her room. The event was witnessed by a housekeeper, who immediately reported it to the facility Administrator. Subsequent interviews confirmed that several staff members were aware of the allegation, and the Director of Nursing (DON) acknowledged that the Administrator had been informed and had conducted some interviews related to the incident. Despite the facility's policy requiring immediate reporting of abuse allegations to the Ohio Department of Health (ODH), the facility did not complete a Self-Reported Incident or notify ODH as mandated. The investigation conducted by the Administrator did not include all potential witnesses, specifically two CNAs in training who were present at the time of the incident. The facility's policy clearly outlined the requirement to report all allegations of abuse or serious bodily injury to ODH within specified timeframes, which was not followed in this case.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with severe cognitive impairment and multiple medical diagnoses, including senile degeneration of the brain, hypertension, diabetes mellitus, and unspecified psychosis. The incident involved a CNA allegedly taking a photo of the resident while she was topless in her room, as witnessed by a housekeeper who immediately reported the event to the Administrator. The Director of Nursing confirmed that the Administrator interviewed some witnesses and the accused CNA, who denied the allegation, but did not interview two CNAs in training who were also present at the time of the incident, as indicated in witness statements. Additionally, there was no documentation to support that any other residents on the hall were interviewed for concerns of abuse. The facility's investigation documentation did not include interviews with all potential witnesses, specifically the two CNAs in training, nor did it show that a Self-Reported Incident was completed or that the Ohio Department of Health was notified as required by facility policy and regulations. The facility policy mandates immediate reporting and thorough investigation of all alleged violations involving abuse, including interviewing the resident, the accused, and any witnesses. The failure to follow these protocols resulted in a deficient practice regarding the investigation of the abuse allegation.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Piqua
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ayden Healthcare Of Piqua | 3.6 mi | ★★★★★ | 0 | 0 |
| Vancrest-upper Valley | 4.8 mi | ★★★★★ | 0 | 0 |
| Stillwater Skilled Nursing And Rehabilitation | 4.8 mi | ★★★★★ | 11 | 0 |
| Troy Rehabilitation And Healthcare Center | 8.2 mi | ★★★★★ | 18 | 0 |
| Fair Haven Shelby County | 9.4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.