Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carecore At Lima during CMS and state inspections, most recent first.
Failure to Complete Legionella Water Testing: The facility did not complete required Legionella water testing as part of its infection prevention and control program. Review of records and staff interviews showed that water samples were last tested by the water consultant, and no further testing had been completed since then. The Maintenance Director and VOP confirmed the facility was supposed to obtain annual Legionella testing, but testing had not occurred and the facility was waiting for delivery of testing kits. Facility policy and CDC guidance both referenced routine Legionella monitoring and validation sampling.
A resident with multiple chronic conditions, including Alzheimer’s disease, diabetes, CHF, and hemiplegia, had a care plan for dental caries and oral health needs. Dental notes showed the resident refused teeth cleaning on two occasions, but the record did not show that the resident’s representative was notified of those refusals, despite the resident having moderate cognitive impairment and documented dental problems.
Failure to complete ordered surgical wound care for a resident with a left lower leg surgical site. The resident was cognitively intact and had an order for wound cleansing, skin prep, blue foam, and a bordered gauze dressing to be changed 3 times weekly and PRN. Observation and interviews showed the dressing was still in place from the prior change date and appeared soiled, and both the resident and an RN confirmed it had not been changed as ordered. The DON later stated the treatment record entry showing the dressing change was an error in documentation.
Failure to arrange timely ophthalmology services for a resident with cataracts, diabetes, Alzheimer's disease, and impaired vision. The resident had an order for an eye specialist referral, but there was no evidence the referral was made or that an appt was scheduled until the DON confirmed it had not been completed and later arranged one after the deficiency was identified.
A resident with DM, Alzheimer's disease, CHF, and moderate cognitive impairment received dialysis three times per week, but the record lacked ongoing pre- and post-dialysis communication forms between two documented entries. An LPN confirmed the missing documentation and stated staff were expected to complete these forms with each dialysis treatment. The facility policy required coordination between LTC and ESRD dialysis teams.
Failure to post daily nurse staffing information. Observations in the lobby and common areas showed the staffing information was not displayed for residents, staff, or visitors to review. An MDS staff member stated she reviewed the staffing totals and hours worked with management in the morning meeting, but did not post the information for residents or family to review, and confirmed it had not been posted.
A cognitively intact resident with multiple chronic conditions reported that his medications, specifically pain medications, were being taken while he was being transported to the hospital. The facility’s self-reported incident stated that a thorough investigation was completed and the allegation was unsubstantiated, but the investigation file contained no staff interview statements and no documented interview with the resident to clarify which medications were involved or when they were taken. The DON and a UM confirmed that no formal statement was obtained from the resident before or during his hospital stay, and no staff interviews were documented, contrary to facility policy requiring comprehensive investigative interviews and documentation for alleged misappropriation.
A resident with multiple chronic conditions and moderate cognitive impairment was discharged home without the facility involving her POA in the discharge planning process, despite documentation that the POA had previously provided input favoring long-term placement and a care plan intervention for social services to meet with both resident and family to determine the discharge plan. The resident met with a PA, signed a discharge packet with medication and home health orders, and was picked up by family on the day of discharge, but there was no documented consultation or prior notification to the POA. The DON acknowledged that the family was not included in the discharge discussion, which conflicted with the facility’s discharge planning policy requiring collaborative planning and documentation of resident and representative notification.
A resident with a pressure ulcer on the coccyx was not properly assessed or treated upon admission, leading to the ulcer becoming unstageable with necrosis. The facility failed to notify the physician or implement treatment orders, resulting in the need for surgical intervention. The resident's condition, including spinal stenosis and protein-calorie malnutrition, increased their risk for skin breakdown, yet the facility did not adhere to its documentation and treatment protocols.
The facility failed to prevent falls and ensure a safe environment, resulting in harm to a resident who tripped over an improperly stored mechanical lift, causing a facial laceration and elbow fracture. Additionally, the facility did not conduct neurological checks after falls for another resident and failed to investigate fall incidents thoroughly. A third resident fell out of a wheelchair due to deteriorated concrete, highlighting the facility's failure to address environmental hazards.
The facility failed to complete comprehensive care plans for several residents, leading to deficiencies in addressing their specific medical needs. A resident with an indwelling catheter lacked a care plan for its management, while another with hemiplegia and a catheter had no care plan for bowel/bladder care. A resident on hospice with respiratory needs did not have a respiratory care plan, and another with cerebral infarction lacked a plan for activities of daily living. Additionally, a resident with a cutaneous abscess had no care plan for the actual skin impairment.
The facility failed to provide adequate protein portions to residents on a mechanical soft diet, affecting 14 residents. A staff member used an unlabeled scoop believed to be 3 ounces, but it was found to hold less than 2 and 2/3 ounces. The Dietary Manager and Regional Registered Dietitian could not verify the portion size, while the menu indicated a 3-ounce portion was required.
The facility failed to ensure proper hand hygiene during meal preparation and did not maintain the dishwashing machine at the required temperature. Staff were observed using gloves inappropriately, and the dishwasher's temperature was below the recommended level, potentially affecting resident safety.
The facility failed to maintain a pest-free environment, with multiple observations and interviews confirming the presence of moths in the secured unit. Residents and staff reported discomfort due to the moths, which were attributed to bird food stored inside the building. Despite routine exterminator visits, the issue persisted, affecting 35 residents.
The facility failed to maintain a safe environment, with a significant gap in the wheelchair ramp and broken tiles in the shower area. A resident experienced difficulty navigating the ramp, and another resident with a history of falls slipped in the shower due to the broken tiles. Staff confirmed these issues, and the facility's policy on safety was not followed.
The facility failed to conduct thorough weekly skin assessments for a resident with multiple diagnoses, leaving a skin review form blank. Additionally, two residents did not receive treatments as ordered: one had unwrapped legs despite orders for compression stockings, and another had stitches that were not removed as required. The DON confirmed the assessment omission, and a nurse was unaware of the stitch removal order.
A resident with an indwelling catheter did not have appropriate treatments and services documented. The catheter was noted in the baseline care plan but not in the comprehensive care plans, and there were no physician orders for its care or removal. Staff performed catheter care but could not document it due to the absence of orders. The facility's policy required documentation and assessment of catheter care, which was not adhered to.
A resident with multiple health issues experienced severe dental pain and was not provided with prescribed Hydrocodone-Acetaminophen due to a lack of communication and medication administration failures. Despite high pain levels, the resident did not receive the necessary medication after returning from the hospital, leading to frustration and inadequate pain management.
The facility failed to serve palatable meals, affecting two residents. A test tray review revealed that while the meal presentation was pleasing and the temperature was appropriate, the mashed potatoes, gravy, and broccoli were bland and lacked seasoning. These findings were confirmed by an RN and echoed by two residents who found the mashed potatoes and gravy to be flavorless.
Failure to Complete Legionella Water Testing
Penalty
Summary
The facility failed to implement its infection prevention and control program by not completing water testing for Legionella in accordance with its Legionella plan and policy. Review of the Water Consultant #500 report dated 11/18/24 showed that seventeen water sources in the facility were tested for Legionella, and the facility could not provide evidence that any additional water source testing had been completed after that date. Interviews with the Maintenance Director #225 and the VOP #280 confirmed that the facility was supposed to send out water samples annually for Legionella testing through Water Consultant #500, but the facility had not tested its water for Legionella since 11/18/24. The VOP #280 and Maintenance Director #225 stated the facility was waiting for delivery of the water testing kits. The facility’s Risk Management Plan for Legionella Control, Legionella Surveillance and Detection policy, and Legionella Water Management program policy all described routine monitoring and annual validation sampling, and CDC guidance cited routine environmental sampling in high-risk healthcare settings to confirm the water management program was effective.
Failure to Notify Representative of Dental Refusals
Penalty
Summary
The facility failed to notify the resident's representative of the resident's refusals to be seen by the dentist. Resident #9 was admitted with diagnoses including nontraumatic hemorrhage in the brain stem, left hemiplegia, diabetes mellitus, Alzheimer's disease, primary optic atrophy bilaterally, and congestive heart failure. The resident's dental care plan identified oral/dental health problems related to dental caries and included interventions to coordinate dental care and transportation as needed or ordered. Dental treatment notes showed the resident refused to have teeth cleaned on two occasions, but the medical record did not contain documentation that the resident's representative was notified of those refusals. The MDS assessment indicated the resident had moderate cognitive impairment and had obviously or likely cavities or broken natural teeth. The resident's representative stated the resident complained of tooth pain often during visits and was not sure when the resident was last seen by the dentist or refused dental care. The Social Service Director confirmed the representative had been involved in care conferences and had visited the resident at times, but there was no documentation that the representative had been updated about the dental refusals.
Failure to Complete Ordered Surgical Wound Care
Penalty
Summary
The facility failed to ensure surgical wound care was completed as ordered for one resident with a surgical wound to the left medial lower leg. The resident was admitted with diagnoses including aftercare following surgical care, nontraumatic compartment syndrome of the left lower extremity, and a disorder of the circulatory system. The resident was cognitively intact and had a surgical wound with treatment in place. The physician's order required the wound to be cleansed, skin prep applied to the peri-wound area, blue foam placed to the wound bed, and the site covered with a large bordered gauze dressing every Monday, Wednesday, and Friday and as needed. Review of the treatment record showed documentation that the dressing was completed on a Friday, but observation and interviews on the following Monday revealed the dressing was still dated from the prior Wednesday and appeared soiled with a brown substance on the outside. The resident stated the dressing had not been changed since the prior Wednesday, and an RN confirmed the dressing had not been changed as ordered. The DON later confirmed the treatment record entry showing the dressing change was an error in documentation. The wound evaluation later showed the surgical site remained open with slough and delayed wound closure.
Failure to Arrange Timely Ophthalmology Referral
Penalty
Summary
The facility failed to timely schedule an ophthalmology appointment as ordered for a resident with left hemiplegia, diabetes mellitus, Alzheimer's disease, and primary optic atrophy bilaterally. The resident's medical record showed an order dated 03/25/26 for referral to an ophthalmologist for cataracts, and the MDS dated 05/27/26 documented moderate cognitive impairment, impaired vision, and no glasses. The vision care plan identified a potential for impaired visual function related to cataracts and diabetic proliferative retinopathy and included arranging consultation with eye care practitioners as required. However, there was no evidence that the resident was seen by an ophthalmologist or that an appointment had been scheduled, and the DON confirmed on 06/03/26 that the facility had not made the referral as ordered. The DON also stated the resident had previously refused an ophthalmology appointment in 2025 and that a new appointment was made on 06/03/26 for 08/17/26.
Missing Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis facility regarding dialysis care and services for one resident who received dialysis. The resident had diagnoses including diabetes mellitus, Alzheimer's disease, and congestive heart failure, and the MDS indicated moderate cognitive impairment and dialysis treatment. Physician orders directed dialysis at the dialysis center three times per week. Review of the resident's pre- and post-dialysis communication forms showed documentation dated 03/21/26 and 05/21/26, with no documentation to support that these forms were completed between those dates. An LPN confirmed the medical record lacked documentation for the missing pre- and post-dialysis communication forms and stated staff were expected to complete these forms with each dialysis treatment. The facility policy stated dialysis care was to be coordinated between LTC and dialysis teams.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information for residents, staff, and visitors to view. Observations in the main lobby and common areas on 06/01/26 at 9:00 A.M., 06/02/26 at 10:00 A.M., and 06/03/26 at 10:00 A.M. showed that the daily nurse staffing was not posted. During an interview on 06/03/26 at 10:14 A.M., Medical Record Staff #204 stated she reviewed the daily nurse staffing total numbers and hours worked with the management team in the daily morning meeting, but she did not post the information for residents or family to review. She confirmed the facility had not posted the nurse staffing information.
Failure to Thoroughly Investigate Allegation of Medication Misappropriation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of misappropriation involving one resident. The cognitively intact resident, who had multiple medical diagnoses including muscle wasting and atrophy, COPD, hypotension, severe sepsis, atherosclerotic heart disease, hypothyroidism, hyperlipidemia, CHF, anxiety disorder, atrial fibrillation, obstructive and reflux uropathy, and major depressive disorder, reported that his medications were being taken while he was being transported to the hospital. The facility submitted a Self-Reported Incident indicating that a thorough investigation had been completed and the allegation was unsubstantiated. However, review of the facility’s investigation packet revealed there were no staff interview statements and no documented interview with the resident to determine which medications were allegedly taken, when they were taken, or to obtain other specific information about the allegation. The DON and a Unit Manager confirmed that no staff interview statements were documented and that no formal statement was obtained from the resident before he left for the hospital, nor was he contacted or interviewed at the hospital. These omissions were inconsistent with the facility’s own policy, which requires thorough documentation and investigation steps including interviews with the resident, reporter, staff on all shifts, and others, as well as complete documentation of findings.
Failure to Involve POA in Discharge Planning
Penalty
Summary
The facility failed to include a resident’s family/Power of Attorney (POA) in the discharge planning process, contrary to the resident’s care plan and facility policy. The resident had multiple complex medical diagnoses, including encephalopathy, peripheral vascular disease, malnutrition, acute and chronic respiratory failure, emphysema, congestive heart failure, chronic kidney disease, and other chronic conditions, and had a BIMS score of 10 indicating moderate cognitive impairment. A care conference document showed the current discharge plan was for the resident to remain in the facility for long-term placement, with the resident present but her family not in attendance. The resident’s care plan documented that she wished to return to the community, but also reflected that, per the POA, she was considered a possible long-term placement. The care plan included an intervention that social services would meet with the resident and family on admission to determine the discharge plan. Progress notes showed that the resident met with a physician assistant to discuss an upcoming discharge home and that both the resident and the physician assistant signed the discharge packet, which included medication orders and home health orders. However, review of progress notes for the days leading up to the discharge revealed no evidence that the facility consulted with or notified the resident’s family or POA about the discharge prior to the day it occurred, when the family member received a call from the resident to pick her up. The family member, who confirmed she was the POA and wanted to be kept up to date on all care and changes, reported that she had not been consulted about this discharge and that prior notifications had been inconsistent. The DON confirmed that the discharge process had not been discussed with the family before it occurred, despite the care plan and the facility’s discharge planning policy requiring collaborative planning with the resident and representative and documentation of resident and representative notification.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident admitted with a pressure ulcer on the coccyx. Upon admission, the resident was noted to have a non-blanchable purple wound on the coccyx, but the staff did not accurately assess the wound, including taking measurements or providing a description. Furthermore, the staff failed to notify the physician to obtain and implement treatment orders. This lack of action resulted in the pressure ulcer becoming unstageable with necrosis, requiring surgical intervention. The resident, who had diagnoses including spinal stenosis, cord compression, malignant neoplasm of bone, and protein-calorie malnutrition, was dependent on two-assist for activities of daily living. Despite being at risk for skin breakdown, the facility did not conduct proper wound assessments or document the condition of the pressure ulcer from the time of admission until it was evaluated by a wound physician. The wound was not treated or monitored adequately, leading to its deterioration. The facility's documentation and treatment protocols were not followed, as evidenced by the lack of wound assessments and physician notifications. The wound was only properly assessed and treated after it had significantly worsened, necessitating excisional debridement surgeries. The facility's policies required accurate documentation and timely interventions, which were not adhered to in this case, resulting in actual harm to the resident.
Plan Of Correction
Immediate Actions Taken: On 3-11-25, the treatment nurse conducted a skin assessment on Resident #43. At this time, the wound was measured, staged, documentation completed, and wound doctor notified. Treatment continued per order. CP was reviewed to ensure all appropriate interventions were in place. Identification of like residents having the potential to be affected: Skin assessments were completed for all residents by 03-12-25 by the nursing management team. No new wounds were identified. Actions taken/systems put into place to reduce the risk of future occurrences included: The treatment nurse was provided education on or before 3-12-25 by the DON related to the expectation to conduct a 2nd skin check on all new admissions within 48 hours of admission and to ensure all skin checks are completed weekly. All direct care staff was educated on or before 3-24-25 by DON/Designee regarding Pressure Injury Prevention, completing a full skin assessment on admission and ongoing weekly, timely reporting of newly discovered skin alterations, and ensuring interventions/treatments are in place. 100% compliance was achieved, as evidenced by a signed attestation. Ongoing Monitoring: The treatment nurse will audit all admission skin assessments and ongoing weekly skin assessments, interventions/treatments, and notifications as required for completeness weekly x 4 weeks and monthly x 3 months and as needed thereafter. The DON/designee will also complete audits to ensure the treatment nurse is completing 2nd skin assessments within 48 hours of a newly admitted resident by auditing one admission weekly x 4 weeks, monthly x 3 months, and prn thereafter. The DON/designee will audit 3 random residents' weekly skin assessments for completeness and accuracy weekly x 4 weeks, monthly x 3 months, and prn thereafter. Findings will be reviewed by the QAPI Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Prevent Falls and Ensure Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment to prevent falls, resulting in actual harm to Resident #23, who tripped over the legs of an improperly stored mechanical lift. This incident led to a facial laceration requiring stitches and a fractured left olecranon. The resident, who had impaired cognition and required supervision for transfers and walking, was walking with aides when the fall occurred. The mechanical lift was improperly stored in the hallway, reducing the usable width of the walkway, which contributed to the fall. Additionally, the facility failed to conduct neurological checks after falls for Resident #22 and did not thoroughly investigate fall incidents for Residents #22 and #63. Resident #22, who had impaired cognition and was at risk for falls, experienced multiple falls without proper interventions being implemented. The facility did not ensure that fall prevention measures, such as a fall mat, were in place, and there was no evidence of neurological checks being completed after unwitnessed falls. The facility also failed to provide a safe environment for Resident #52, who fell out of a wheelchair due to deteriorated concrete outside the facility. The resident, who was dependent on a wheelchair for ambulation, attempted to propel himself outside and fell into a hole in the concrete. The facility's investigation noted the fall was witnessed, but no injuries were reported. The facility did not address the environmental hazard that contributed to the fall, as the broken concrete and raised edges remained unrepaired.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were completed for all care areas for several residents, leading to deficiencies in their care. Resident #130, who was admitted with an indwelling catheter due to obstructive uropathy, did not have a comprehensive care plan addressing the catheter. Despite receiving regular catheter care, there were no physician orders or documentation in the medical records regarding the catheter's care or continuation. Interviews with staff confirmed the lack of documentation and care planning for the catheter. Resident #22, admitted with hemiplegia, hemiparesis, and an indwelling catheter, also lacked a comprehensive care plan addressing bowel/bladder or catheter care. Observations confirmed the presence of the catheter, and interviews with staff verified the absence of a care plan for these areas. Similarly, Resident #41, who required respiratory support and was on hospice, did not have a respiratory care plan, despite being dependent on staff for activities of daily living and having a tracheostomy. Resident #57, with diagnoses including cerebral infarction and congestive heart failure, lacked a care plan for activities of daily living, despite being dependent on staff for mobility and transfers. Additionally, Resident #71, who had a cutaneous abscess on the buttock, did not have a care plan addressing the actual skin impairment, although there was a plan for the risk of skin impairment. Interviews with the Director of Nursing confirmed the absence of appropriate care plans for these residents, highlighting a systemic issue in the facility's care planning process.
Inadequate Protein Portions for Mechanical Soft Diet
Penalty
Summary
The facility failed to provide adequate protein portions to residents on a mechanical soft diet, affecting 14 residents out of a census of 80. During meal service, it was observed that a staff member was using a green handled scoop to plate mechanical soft pork loin, which was believed to be a 3-ounce scoop. However, upon further investigation, it was found that the scoop had no measurements, and another similar scoop measured 2 and 2/3 ounces. The Dietary Manager confirmed the scoop had no measurements, and a comparison with a labeled scoop showed the unlabeled scoop held less than 2 and 2/3 ounces. The Regional Registered Dietitian could not verify the portion size provided to residents, and the menu spreadsheet indicated the portion should be 3 ounces.
Deficiencies in Hand Hygiene and Dishwashing Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during meal preparation, as observed on two separate occasions. During the first observation, a staff member was seen wearing disposable gloves while plating roast beef sandwiches and cubed potatoes. The staff member used her hands to handle various food items and changed gloves without washing her hands, which is against the facility's policy. The Dietary Manager confirmed the inappropriate hand hygiene practices and acknowledged that touching bags of bread or rolls was considered a contaminated surface. In a second observation, another staff member was seen using the same pair of gloves to handle bread and scoop meat, confirming she should have changed gloves before touching ready-to-eat food. Additionally, the facility failed to maintain the dishwashing machine at the proper temperature, as required by the manufacturer's guidelines. The dishwasher's wash temperature was observed to be below the minimum recommended temperature of 120 degrees Fahrenheit, with readings of 91 degrees and 108 degrees Fahrenheit during multiple cycles. The Dietary Manager confirmed that the wash temperature did not meet the minimum requirements, which could potentially affect the cleanliness and safety of the dishes used by residents.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by multiple observations and interviews revealing the presence of moths in the secured unit. On several occasions, moths were observed flying around the dining room and residents' rooms, causing discomfort to the residents. Interviews with residents and staff confirmed the presence of moths, with some residents expressing their annoyance. A Licensed Practical Nurse (LPN) mentioned that the exterminators attributed the moth problem to bird food stored inside the building for outdoor bird feeders. Despite the routine visits from the exterminator company, the issue persisted, and the receipts from the exterminator did not specifically mention moths. The Maintenance Director, who had been with the facility for two months, was unaware of the moth issue, although the exterminator company was noted to be responsive to facility concerns. The facility's policy on maintaining a clean, sanitary, and orderly environment was not effectively implemented, as evidenced by the ongoing moth problem. The LPN did not report the moth issue, assuming it was evident to maintenance and other staff. The facility's failure to address the moth infestation potentially affected 35 residents in the secured unit, highlighting a deficiency in maintaining a pest-free environment.
Deficiencies in Wheelchair Ramp and Shower Safety
Penalty
Summary
The facility failed to maintain a safe environment concerning the wheelchair ramp at the front of the building, which posed a risk to all residents using wheelchairs. Observations revealed a five-inch gap with exposed stone and grass at the top of the ramp, causing difficulty for residents and staff. An incident was noted where a State Tested Nursing Assistant (STNA) struggled to push a resident's wheelchair over the gap, requiring multiple attempts. Interviews with residents and staff confirmed the challenges posed by the gap, and the facility's policy on providing a safe environment was not adhered to. Additionally, the facility did not ensure the shower floor in the secured unit was free of broken tiles, affecting a resident with a history of falls and impaired cognition. The resident experienced multiple falls in the shower, reportedly due to the slippery and broken tiles, which were confirmed by staff observations. The Maintenance Director, unaware of the broken tiles, confirmed their presence upon inspection. The Director of Nursing was aware of the falls but not of the specific cause related to the broken tiles. This deficiency was investigated under a complaint.
Deficiencies in Skin Assessments and Treatment Adherence
Penalty
Summary
The facility failed to ensure thorough weekly skin assessments for a resident with multiple diagnoses, including type two diabetes and cutaneous abscesses. The medical record for this resident showed a blank skin review form, lacking necessary details such as wound description, measurements, and treatment orders. The Director of Nursing confirmed the omission, acknowledging that the assessments should have been completed thoroughly. Additionally, the facility did not adhere to treatment orders for two other residents. One resident, with conditions like myoneural disorder and congestive heart failure, was observed with unwrapped legs despite orders for compression stockings and wraps. The resident reported inconsistent care, and a nurse claimed the resident refused treatment, which the resident denied. Another resident, with cerebral infarction and dementia, had stitches that were not removed as ordered. The nurse on duty was unaware of the removal requirement, as no hospital paperwork was received upon the resident's return.
Failure to Document and Plan Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatments and services for a resident with an indwelling catheter. The resident was admitted with a catheter due to obstructive uropathy, but there were no physician orders or comprehensive care plans addressing the catheter's care or removal. Despite the catheter being noted in the baseline care plan, it was not included in the comprehensive care plans, and there was no documentation of catheter care in the medical records. Interviews with staff revealed that catheter care was performed, but there was no place to document it due to the absence of orders. The resident expressed uncertainty about the plan for the catheter and reported that nurses informed him it would be removed when no longer needed. The Director of Nursing and a Regional Registered Nurse confirmed the lack of documentation and orders for the catheter. The facility's policy required staff to assess the ongoing need for catheters and document all care, which was not followed in this case.
Failure to Provide Prescribed Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident #33, who was prescribed Hydrocodone-Acetaminophen for dental pain. The resident was admitted with multiple diagnoses, including hemiplegia and heart disease, and had a care plan that included administering medications per physician orders. Despite being prescribed pain medication following hospital visits for dental pain and infection, the facility did not administer the medication as ordered. The resident's pain levels were documented as high, reaching eight out of ten on several occasions. The resident experienced severe dental pain and requested narcotic pain medication, which was not available due to a lack of a written script in the records. This led the resident to sign out of the facility to seek treatment at a hospital, where they received prescriptions for pain medication and antibiotics. Upon returning to the facility, the resident continued to experience pain and was not provided with the prescribed medication due to a pharmacy issue that was not communicated to the facility. The resident reported that the pain was mostly at night, causing loss of sleep, and refused Tylenol due to adverse effects. Interviews with the resident, social worker, RN, and DON revealed that the resident's pain management was inadequate due to a failure in communication and medication administration. The resident expressed frustration over not receiving the necessary medication and the delay in dental procedures. The DON confirmed that the pharmacy did not supply the medication and that the resident had not received any pain medication after reporting pain, highlighting a significant lapse in the facility's pain management protocol.
Facility Fails to Serve Palatable Meals
Penalty
Summary
The facility failed to serve palatable meals, affecting two residents. During a test tray review, a meal consisting of roast pork loin, mashed potatoes, and broccoli was evaluated. The plate presentation was pleasing, and the food temperature was warm. However, the mashed potatoes and gravy were found to be bland with minimal flavor, and the broccoli, although cooked to an appropriate texture, was also bland and unseasoned. These observations were confirmed by Registered Nurse #178. Interviews with two residents revealed similar concerns, as they both described the mashed potatoes and gravy as lacking flavor.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 114 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lima
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springview Manor | 1.8 mi | ★★★★★ | 0 | 0 |
| Lima Convalescent Home | 2.8 mi | ★★★★★ | 1 | 0 |
| Lost Creek Rehabilitation And Nursing Center | 2.9 mi | ★★★★★ | 11 | 0 |
| Shawnee Manor | 3.6 mi | ★★★★★ | 1 | 0 |
| Liberty Retirement Community Of Lima Inc | 4 mi | ★★★★★ | 34 | 1 |
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