Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Shawnee Manor during CMS and state inspections, most recent first.
A resident with multiple respiratory and cardiac diagnoses, including CHF, OSA, bronchiectasis, and chronic respiratory failure, had a care plan directing nightly BiPAP/CPAP use, but the facility lacked corresponding physician orders for the therapy and did not document nightly administration in the TARs, task worksheets, or nursing notes. The only related order was for weekly cleansing of the BiPAP mask. The resident’s family reported that CPAP had been ordered on admission and that the resident was not consistently using the device as ordered, nor was the family informed of refusals. The Administrator and DON confirmed the absence of necessary BiPAP/CPAP orders and documentation, resulting in a cited deficiency.
The facility failed to properly store medications, with issues including undated opened medications, food stored with biologicals, and medications not labeled with resident names. Observations revealed opened ear drops without a date, an insulin pen without an open date, and outdated tuberculin derivative. Food items were found in a medication cart with biologicals, and Cymbalta packages lacked resident identification.
The facility failed to ensure call lights were within reach for three residents, affecting their ability to communicate needs. A resident with spastic hemiplegia had a call light stuck between the mattress and handrail, another with cerebral palsy had a touch call light on the nightstand, and a third with cognitive deficits had a call light on the floor. Staff confirmed these observations and repositioned the call lights.
A resident dependent on staff for bathing did not receive proper hygiene care, as CNAs placed soiled washcloths back into the basin of warm water during the bathing process, violating infection control measures. The resident had multiple medical conditions, including pressure ulcers, and required assistance for bathing. The facility's policy was not followed, compromising the resident's care.
A facility failed to follow a physician's orders for treating a resident's skin tear. The resident, who was cognitively intact and had a history of several medical conditions, had a skin tear on the left forearm. The physician ordered daily cleansing and dressing changes, but the treatment was not performed as documented. An LPN confirmed the discrepancy, noting the dressing was incorrectly dated and not changed as ordered.
A facility failed to apply hand and foot splints per physician orders for a resident with dementia and contractures. The care plan required specific orthoses and braces to be applied by CNAs, but documentation showed a lack of compliance over the past 30 days. Observations confirmed the absence of required splints, and no refusal by the resident was documented, indicating non-adherence to the care plan.
A facility failed to follow physician orders for a resident's respiratory care, specifically regarding the weekly change of oxygen equipment. The resident, who was cognitively intact and had heart failure and depression, had an oxygen humidification bottle that had not been changed since late December, despite orders for weekly changes. This was confirmed by an LPN and was against the facility's policy.
A facility failed to implement enhanced barrier precautions during catheter and ostomy care for a resident with multiple diagnoses, including a urinary tract infection and dementia. Despite the care plan and facility policy indicating the use of gowns and gloves for high-contact activities, staff were observed performing care without gowns. Both a nurse and a CNA confirmed the lack of gown use, citing that the resident was no longer on any kind of precaution.
A resident with severe cognitive impairment and a history of falls was not provided with appropriate fall interventions. Despite a previous fall due to fatigue, the resident was placed in the wrong wheelchair, leading to another fall and injury. The facility's Fall Reduction Policy was not adequately followed.
The facility failed to provide showers twice weekly to two residents as required by their care plans. One resident, with diagnoses including dementia and diabetes, received showers only three times in 30 days, while another severely cognitively impaired resident received showers only twice. The DON confirmed the lack of documentation for these showers, indicating non-compliance with the facility's policy on activities of daily living.
The facility failed to maintain infection control during incontinence care for two residents. A CNA did not change gloves or perform hand hygiene while providing care to a cognitively impaired resident, and another CNA used the same gloves throughout the care process for a cognitively intact resident. These actions violated the facility's glove use policy, which requires hand cleaning after glove removal.
Failure to Implement and Document Ordered BiPAP/CPAP Therapy
Penalty
Summary
The facility failed to ensure that a resident’s BiPAP/CPAP therapy was implemented and documented according to physician recommendations and the resident’s care plan. The resident, who had diagnoses including congestive heart failure, obstructive sleep apnea, bronchiectasis, and chronic respiratory failure, was care planned on 05/18/22 as being at risk for altered respiratory status, with an intervention to assist in ensuring the BiPAP/CPAP mask was in place nightly per order. The quarterly MDS showed the resident had intact cognition and was receiving non-invasive oxygen therapy. However, review of physician orders from 08/11/22 through discharge on 10/14/25 revealed no physician order for BiPAP/CPAP therapy, aside from an order dated 05/04/24 directing staff to cleanse the BiPAP mask weekly on Sundays. Review of the resident’s medical record, including TARs, task worksheets, and nursing progress notes, showed no evidence that BiPAP/CPAP therapy was administered nightly as indicated in the care plan. The resident’s family representative reported that there had been an order for CPAP upon admission and stated the facility did not ensure the resident was using the CPAP machine as ordered, and that she was not informed when the resident refused the therapy. In an interview, the Administrator and DON confirmed that the medical record lacked documentation of BiPAP/CPAP administration and acknowledged there were no physician orders to administer it nightly, although there should have been. This deficiency was cited under Complaint Number 2705837.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage protocols, as evidenced by several observations and interviews. In the F-hall medication cart, an opened bottle of generic ear drops was found without an open date, which was confirmed by an LPN. Similarly, the A-hall medication cart contained an unmarked medication cup with various tablets and an opened insulin pen without an open date, as verified by another LPN. Additionally, the memory care unit's medication room had an opened vial of tuberculin derivative dated over 30 days prior, which should have been disposed of according to the staff developer. Further deficiencies were noted in the D-hall medication cart, where food items were stored alongside biologicals, including hemorrhoidal cream. Eleven packages of Cymbalta without resident names and undated artificial tears were also found. These findings were confirmed by an LPN. The facility's policy on medication storage, which requires medications to be stored in legally compliant containers and outdated medications to be removed immediately, was not followed, leading to these deficiencies.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident #31, who was admitted with diagnoses including spastic hemiplegia and cognitive impairment, was observed with her call light stuck between the mattress and handrail, making it inaccessible. This was confirmed by a Certified Nursing Assistant (CNA) who verified the call light was out of reach. Similarly, Resident #235, with a history of cerebral palsy and intellectual disabilities, was found with her touch call light placed on the nightstand, out of her reach. A Registered Nurse confirmed this observation and repositioned the call light. Additionally, Resident #104, diagnosed with cognitive communication deficit and mood disorders, was observed with her call light on the floor at the foot of the bed, out of reach. A CNA verified this and placed the call light within reach. These observations indicate a failure to adhere to care plans that required call lights to be accessible to prevent falls and ensure residents could communicate their needs effectively.
Failure to Maintain Hygiene and Infection Control During Bathing
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for bathing received the necessary services to maintain good hygiene. The resident, who was cognitively intact, had multiple medical conditions including skin infection, diabetes mellitus, and pressure ulcers on the buttocks. The resident required assistance from staff for bathing due to impaired bilateral lower extremities and was at risk for decline in activities of daily living (ADL) due to various health issues. The plan of care indicated that the resident was totally dependent on staff for toileting and required one to two staff members for bathing. During an observation, two CNAs were performing a bath for the resident. CNA #623 washed the resident's back and legs, which had open wounds, using a washcloth that was then placed back into the basin of warm water, potentially contaminating it. This process was repeated for washing the resident's buttocks. The CNAs later confirmed that the soiled washcloths should not have been placed back into the basin, as this action did not adhere to infection control measures. The facility's policy stated that each resident should receive care to maintain their highest practical well-being, but the actions observed during the bathing process did not align with this policy.
Failure to Follow Physician's Orders for Skin Tear Treatment
Penalty
Summary
The facility failed to ensure that a resident's treatment for a skin tear was completed as ordered by the physician. The resident, who was cognitively intact and had a medical history including carpal tunnel syndrome, type two diabetes mellitus, cognitive heart failure, and major depressive disorder, had a skin tear on the left forearm. The physician's order required the skin tear to be cleansed with normal saline, treated with triple-antibiotic ointment, and covered with bordered gauze every day shift. However, the treatment administration record indicated that the dressing was documented as completed on three consecutive days, but an observation revealed that the dressing was dated incorrectly and had not been changed as ordered. An LPN confirmed that the treatment was documented as completed but had not been performed, and the dressing was not changed as per the physician's order.
Failure to Apply Splints as Ordered for Resident with Contractures
Penalty
Summary
The facility failed to ensure that hand and foot splints were applied per physician orders for a resident with multiple diagnoses, including dementia, schizoaffective disorder, and contractures. The resident's care plan required the use of a left wrist hand finger orthosis, a right c-splint elbow brace, PRAFO boots, and palm protectors due to muscle weakness, contractures, and pain. The care plan also specified that certified nursing assistants (CNAs) were to apply these braces as ordered and provide passive range of motion exercises before and after application. However, a review of the electronic medical record revealed a lack of documentation regarding the application of bilateral hand splints for the past 30 days. On the day of observation, the resident was seen in a wheelchair without any braces or splints on their hands, elbows, or lower extremities. This was confirmed by a Business Office Manager who verified the absence of the required splints and braces. The facility's policy on range of motion, revised in 2016, mandates that residents with limited range of motion receive appropriate treatment to increase or prevent further decrease in range of motion. Despite this policy, there was no documentation of the resident refusing the braces, indicating a failure to adhere to the prescribed care plan and physician orders.
Failure to Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the maintenance of respiratory equipment for a resident. Resident #12, who was cognitively intact and had diagnoses including cognitive heart failure and major depressive disorder, was affected by this deficiency. The physician's orders, dated 04/07/24, specified that the resident's oxygen tubing, supply bag, and water jug should be changed weekly, and the concentrator should be wiped down and its filter cleaned weekly. However, an observation on 02/11/25 revealed that the oxygen concentrator's humidification bottle was last changed on 12/29/24, indicating a failure to follow the weekly change order. This was confirmed by an LPN during an interview. The facility's policy also required that disposable supplies be dated when changed, and that O2 humidifier bottles be changed weekly or as needed.
Failure to Implement Enhanced Barrier Precautions During Care
Penalty
Summary
The facility failed to ensure staff implemented enhanced barrier precautions (EBP) during catheter and ostomy care for Resident #79, who was admitted with multiple diagnoses including urinary tract infection, multiple sclerosis, and dementia. The resident required extensive assistance for bed mobility and was totally dependent on staff for toileting, with an indwelling catheter and ostomy. Despite the care plan indicating that Resident #79 may be in EBP and staff may wear appropriate personal protective equipment (PPE) during high-contact care activities, observations and interviews revealed that staff did not consistently wear gowns during catheter and ostomy care. During an observation, RN #402 performed ostomy replacement without wearing a gown, despite the sign above the resident's bed indicating that gowns and gloves should be used for high-contact activities. Similarly, CNA #520 performed catheter care without wearing a gown, only using gloves. Both staff members confirmed the lack of gown use, with RN #402 stating that the resident was no longer on any kind of precaution. The facility's policy on standard precautions indicated that an impervious gown should be worn during high-contact activities, including care for indwelling medical devices, regardless of MDRO colonization status.
Failure to Implement Fall Interventions for a Resident
Penalty
Summary
The facility failed to ensure a fall intervention was in place for Resident #335, who was severely cognitively impaired and had a history of repeated falls. The resident was admitted with diagnoses including depression, chronic kidney disease, malnutrition, atrial fibrillation, and seizures. On 01/12/25, Resident #335 was found lying on the floor in her room, and a root cause analysis determined the fall was due to fatigue after lunch. The interdisciplinary team decided to change the resident's wheelchair and encourage rest after lunch as interventions. However, on 01/18/25, Resident #335 was found on the floor in the dining room with a small abrasion and bleeding to the corner of her right eye, requiring an ER visit. It was determined that the resident was not in the correct tilt wheelchair, as staff had mistakenly placed her in the wrong one. The facility's Fall Reduction Policy mandates identifying residents at risk for falls and implementing a fall reduction program, which was not adequately followed in this case.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers twice weekly to two residents, #25 and #40, as required by their care plans. Resident #25, who was admitted with diagnoses including disorders of the bladder, repeated falls, dementia, and diabetes mellitus type II, was cognitively impaired and dependent on staff for personal hygiene. The Certified Nursing Assistant (CNA) documentation indicated that Resident #25 received showers on only three occasions over a 30-day period, with one refusal noted. Similarly, Resident #40, who was severely cognitively impaired and dependent for all activities of daily living, received showers on only two occasions in the same timeframe. The Director of Nursing confirmed that the showers were not documented as having been provided to these residents, indicating a lapse in adherence to the facility's policy on activities of daily living. The policy, dated April 29, 2016, mandates that the facility provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being of residents, including personal hygiene. This deficiency was identified during an investigation under Complaint Number OH00159551.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to ensure clean and sanitary incontinence care for two residents, leading to a deficiency in infection prevention and control. Resident #25, who is cognitively impaired and dependent on staff for transfers and toileting, was observed receiving incontinence care from CNA #221. During this care, CNA #221 did not remove soiled gloves or perform hand hygiene before adjusting bed linens and personal items on the overbed table, which is a breach of sanitary protocol. Similarly, Resident #63, who is cognitively intact but dependent on staff for toileting hygiene, was observed receiving morning and incontinence care from CNA #227. CNA #227 used the same gloves throughout the care process, including washing the resident's body, assisting with clothing, and handling personal items, without changing gloves or performing hand hygiene. This was confirmed in an interview with CNA #227, who acknowledged the failure to remove soiled gloves and perform hand hygiene. The facility's policy on glove use, which requires hand cleaning after glove removal, was not followed, contributing to the deficiency.
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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 | 2.6 mi | ★★★★★ | 0 | 0 |
| Springs Of Lima The | 2.7 mi | ★★★★★ | 0 | 0 |
| Lima Convalescent Home | 2.8 mi | ★★★★★ | 0 | 0 |
| Cridersville Nursing And Rehab | 3.6 mi | ★★★★★ | 4 | 0 |
| Carecore At Lima | 3.6 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.