Above average — CMS composite of the measures below.
A standard survey is most likely before around July 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lima Convalescent Home during CMS and state inspections, most recent first.
Surveyors observed improper food storage and preparation practices, including unsealed and undated food in freezers, food boxes stored on the floor, and staff failing to use required hairnets, beard covers, and utensils during food handling. Staff used gloved hands instead of tongs to serve food and did not change gloves or perform hand hygiene between tasks, contrary to facility policy.
The facility did not follow its Legionella control measures, failing to log water temperatures in resident rooms and neglecting to flush water in unoccupied rooms. Additionally, during a wound care procedure, an LPN did not remove gloves or perform hand hygiene as required by policy before continuing with the dressing change for a resident with multiple chronic conditions.
The facility did not ensure that comprehensive and accurate care plans were in place for several residents with complex medical needs, including those with pressure ulcers and those on hospice care. In multiple cases, required care plans addressing wound care or hospice interventions were missing, as confirmed by staff interviews and record reviews.
A resident who was cognitively intact and required supervision for personal hygiene was observed on multiple occasions with visible chin hair, despite expressing a preference for its removal to maintain a feminine appearance. Staff and an LPN confirmed the presence of the chin hair, and facility policy requires grooming assistance according to resident preferences, which was not provided.
A resident with chronic wounds and multiple health conditions did not receive daily dressing changes as ordered by the physician, with a dressing remaining in place for several days. Additionally, required bilateral compression pumps for circulation were not present or applied, as confirmed by both the LPN and the resident. These actions were not in accordance with physician orders or facility policy.
A resident with multiple chronic conditions and a right heel wound did not have a current pressure wound care plan, and facility staff failed to accurately assess and document the wound as a pressure ulcer. Wound treatments were not completed as ordered, with dressings left unchanged beyond the prescribed schedule and inadequate wound description, contrary to facility policy.
A resident with significant medical needs did not receive scheduled showers on two occasions due to insufficient CNA staffing during the night shift. Facility records and interviews confirmed that staffing levels were below the facility's own requirements, resulting in missed care as documented by the DON and staff.
Food Storage and Preparation Deficiencies Observed in Kitchen
Penalty
Summary
Staff failed to maintain proper food storage and preparation practices in the facility's kitchen. During an initial kitchen tour, surveyors observed opened, unsealed, unlabeled, and undated bags of French fries and chicken in the stand-up freezer. Additionally, boxes of frozen cakes and wild caught cod were found stacked directly on the floor of the walk-in freezer. Staff responsible for preparing and serving breakfast was not wearing a hat or hairnet, nor was his full beard covered, as required by facility policy. The Assistant Dietary Manager confirmed these observations during the tour. Further observations during lunch service revealed that a staff member serving tacos did not use tongs to handle cheese, lettuce, tomato, or onion, instead using her gloved hands. She also used her gloved hands to retrieve other food items such as chicken tenders, hamburgers, hotdogs, and fish filets, without changing gloves or performing hand hygiene after touching various surfaces. Two male staff members, including the Food Service Director and a Maintenance Worker, entered the kitchen and tray line area without wearing hairnets or beard covers. Facility policies reviewed required the use of utensils for food handling, proper date marking of food, and adherence to professional food safety standards, all of which were not followed as observed.
Failure to Follow Legionella Control Measures and Infection Prevention During Wound Care
Penalty
Summary
The facility failed to follow its established Legionella control measures as part of its infection prevention and control program. Specifically, the facility did not obtain or log water temperatures for resident rooms and did not perform water flushing in unoccupied resident or shower rooms, contrary to its stated control measures. The Maintenance Director confirmed that there was no log of empty rooms, no flushing of unoccupied rooms regardless of the duration of vacancy, and no ongoing water temperature testing in resident rooms. Additionally, the facility lacked a formal Legionella policy beyond the general control measures outlined in its infection prevention and control program. During a wound care observation, an LPN did not adhere to infection prevention procedures as outlined in the facility's clean dressing change policy. The LPN removed a soiled dressing from a resident's right heel, disposed of it, and then, without removing gloves, handled a saline bottle and a four by four gauze. After cleansing the wound, the LPN removed her gloves but did not perform hand hygiene before donning a new pair of gloves and continuing the dressing change. The LPN acknowledged these lapses in infection control during a post-procedure interview. The resident involved had multiple diagnoses, including diabetes mellitus, chronic ulcer, and chronic osteomyelitis, and required extensive assistance with daily activities.
Failure to Develop and Implement Accurate Care Plans
Penalty
Summary
The facility failed to ensure that care plans were accurate and comprehensive for four residents out of 23 reviewed. Specifically, residents with significant medical conditions such as diabetes, chronic ulcers, osteomyelitis, pulmonary hypertension, dementia, and those on hospice care did not have appropriate care plans addressing their current needs. For three residents with documented pressure ulcers or wounds, there was no corresponding care plan in place to address wound care, despite medical records and wound center documentation confirming the presence of these conditions. In one case, a care plan for a pressure wound was only created after the issue was identified during the survey. Additionally, a resident admitted to hospice care with severe cognitive impairment and a diagnosis of senile degeneration of the brain did not have any goals or interventions documented in the care plan related to hospice care. Staff interviews confirmed the absence of these required care plans. The facility's own policy mandates the development and implementation of comprehensive, person-centered care plans with measurable objectives and time frames to meet residents' medical needs, which was not followed in these cases.
Failure to Maintain Resident Dignity Through Grooming Assistance
Penalty
Summary
Staff failed to maintain the dignity of a resident who was cognitively intact and required supervision for personal hygiene. The resident, admitted with hypertension and osteoarthritis, was care planned for assistance with activities of daily living, including grooming. During observations on two consecutive days, the resident was noted to have multiple chin hairs at least a quarter of an inch long, which were visible while she was eating in the dining room. The resident expressed a desire to appear feminine and stated that staff assist with removing her chin hair. An LPN confirmed the presence of the chin hairs. Facility policy requires that residents be groomed according to their preferences, but this was not followed in this instance.
Failure to Follow Physician Orders for Wound Care and Compression Pump Use
Penalty
Summary
The facility failed to follow physician orders for wound care and use of compression pumps for a resident with multiple diagnoses, including diabetes mellitus, chronic ulcer, and chronic osteomyelitis. The resident required extensive assistance for mobility and had an order for daily dressing changes to the left forearm, specifically to keep steri-strips in place and cover the wound with an island dressing until healed. Observation revealed the dressing on the resident's left forearm was dated seven days prior, despite the order for daily changes, and this was confirmed by the LPN performing the wound care. Additionally, there was a physician order for bilateral compression pumps to be applied twice daily and every evening shift, but observation and interviews confirmed that no compression pumps were present or in use in the resident's room. Facility policy required wound treatments to be completed in accordance with physician orders, including frequency of dressing changes.
Failure to Accurately Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess and document a resident's pressure wound and did not complete wound treatments as ordered. The resident, who had multiple diagnoses including diabetes mellitus, chronic ulcer, and osteomyelitis, required extensive assistance with mobility and had a history of a wound on the right heel. Despite ongoing wound care needs, the care plan did not include a current plan for pressure wound management. Facility wound assessments repeatedly described the wound as 'other' rather than identifying it as a pressure ulcer, and lacked detailed descriptions. The wound care center later identified the wound as a stage three pressure ulcer, but this information was not initially obtained or incorporated by the facility. Additionally, wound treatments were not performed according to physician orders. During an observation, a dressing on the resident's right heel was found to be several days old, despite orders for dressing changes three times weekly. The dressing showed yellow/green drainage, and staff confirmed the treatment had not been completed as scheduled. Facility policy required wound treatments to be completed per physician orders and for pressure ulcers to be differentiated from non-pressure ulcers, but these protocols were not followed.
Failure to Provide Sufficient Staffing for Resident Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, specifically impacting a resident with multiple medical conditions including congestive heart failure, diabetes mellitus, COPD, and a history of stroke. This resident was cognitively intact but dependent on staff for showering, with physician orders specifying showers on certain days during the night shift. Documentation and interviews revealed that the resident did not receive scheduled showers on two occasions when staffing was short, with only one CNA available to cover two houses, each housing up to 12 residents. The resident expressed that showers were missed when staffing was inadequate, and preferred to have showers early in the morning. Review of facility records confirmed the absence of documentation for the missed showers, and the DON verified that if there was no documentation, the shower was not completed. The facility's own assessment indicated that five CNAs were required for the third shift, but on the shift in question, only four CNAs were present, and one called out, leaving insufficient staff to meet resident needs. Facility policy stated that residents should be assisted with bathing to maintain hygiene and prevent skin issues, but this was not followed due to inadequate staffing.
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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 Lima
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springview Manor | 1 mi | ★★★★★ | 0 | 0 |
| Springs Of Lima The | 1.4 mi | ★★★★★ | 2 | 0 |
| Liberty Retirement Community Of Lima Inc | 1.8 mi | ★★★★★ | 24 | 1 |
| Carecore At Lima | 2.8 mi | ★★★★★ | 2 | 0 |
| Shawnee Manor | 2.8 mi | ★★★★★ | 1 | 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 June 2026) and official state health department websites.