Carecore at Lima

Inspectors wroteBased on record review, staff interviews, review of Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to implement their water testing per the facility's Legionella plan and policy. The had the potential to affect all 83 resident in the facility.

Inspectors wroteBased on medical record review and staff and family representative interviews, the facility failed to notify the resident's representative of residents' refusals to be seen by the dentist. This affected one (#9) of 21 residents reviewed for notification of change. reviewed for dental services. The facility census was 83.

Inspectors wroteBased on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure surgical wound care was done as ordered. This affected one (#3) of four residents reviewed for wound care. The facility census was 83.

Inspectors wroteBased on medical record review and staff interview, the facility failed to timely schedule an appointment with an eye specialist as physician ordered. This affected one (#9) of one resident reviewed for vision. The facility census was 83.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure ongoing communication with a dialysis facility regarding dialysis care and services. This affected one (#9) of one resident reviewed for dialysis. The facility identified two residents who received dialysis. The facility census was 83.

Inspectors wroteBased on observations and staff interview, the facility failed to post the nurse staffing information for residents, staff, and visitors to view. This had the potential to affect all 83 residents residing in the facility.

Inspectors wroteBased on medical record review, facility investigative document review, staff interview, and facility policy review, the facility failed to complete a thorough investigation for an allegation of misappropriation. This affected one (Resident #73) of three resident misappropriation allegations reviewed. The census was 71. Findings Include:Resident #73 was admitted to the facility on [DATE]. His diagnoses were muscle wasting and atrophy, chronic obstructive pulmonary disease, hypotension, hypo-osmolality and hyponatremia, severe sepsis, atherosclerotic heart disease,. hypothyroidism, hyperlipidemia, congestive heart failure, anxiety disorder, atrial fibrillation, obstructive and reflux uropathy, and major depressive disorder. Review of his Minimum Data Set (MDS) assessment, dated 02/20/26, revealed he was cognitively intact. [...]

Inspectors wroteBased on medical record review, family interview, staff interview, and facility policy review, the facility failed to include the resident's family/Power of Attorney (POA) in the discharge planning process. This affected one (Resident #72) of three resident discharges reviewed. The census was 71. Findings Include:Resident #72 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on medical record review, review of hospital records, observations, staff interviews, interview with Wound Physician #500, and review of facility policy, the facility failed to timely assess, monitor, and implement treatments for Resident #43, who was admitted to the facility with a pressure ulcer on the coccyx. This resulted in Actual Harm when Resident #43 was assessed upon admission on [DATE] with a pressure ulcer to the coccyx but the staff failed to accurately assess the wound to include measurements/description and the staff failed to notify the physician to obtain/implement treatment orders. Subsequently, Resident #43's coccyx pressure ulcer was assessed by the wound physician on 03/04/25 to be unstageable with necrosis and the coccyx pressure ulcer required excisional debridement (surgery) on 03/04/25 and again on 03/06/25. [...]

Inspectors wroteBased on observations, medical record review, review of fall investigations, staff and resident interviews, review of hospital records, and review of the facility policies, the facility failed to ensure a safe environment to prevent falls, resulting in actual harm when Resident #23 tripped over the legs of an improperly stored mechanical lift resulting in a facial laceration requiring stitches and a fractured left olecranon (elbow) fracture. Further, the facility failed to ensure neurological checks were completed after falls for Resident #22, failed to ensure fall incidents were thoroughly investigated for Resident #22 and Resident #63, and failed to ensure fall preventions were in place for Resident #22. Lastly, the facility failed to ensure a safe environment to prevent falls for Resident #52. This affected four residents (#23, #22, #63, #52) of five residents reviewed for falls. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain a safe environment regarding the wheelchair ramp in the front of the building. This had the potential to affect all residents in wheelchairs who would potentially use the ramp. The facility identified 39 residents who used wheelchairs. Additionally, the facility failed to ensure the floor of the shower in the secured unit was free of broken tiles. This affected one (#63) of one reviewed for falls related to broken tiles. The facility census was 80.

Inspectors wroteBased on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure comprehensive care plans were completed concerning all care areas for residents. This affected five residents (#22, #41, #57, #71, and #130) out of 25 residents reviewed for care plans. The facility census was 80.

Inspectors wroteBased on observation, staff interview, and review of the menu spreadsheet, the facility failed to provide adequate protein portions to residents on a mechanical soft diet. This affected 14 residents (#2, #3, #4, #6, #16, #17, #28, #32, #37, #43, #53, #63, #68, and #130) identified on a mechanical soft diet. The facility census was 80.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure staff used appropriate hand hygiene while preparing meals. Additionally, the facility failed to ensure the dish machine washed dishes at the proper temperature. This had the potential to affect all residents except two (#41 and #42) who were identified as receiving no food from the kitchen. The facility census was 80.

Inspectors wroteBased on observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure a pest free environment. This had the potential to affect 35 residents (#2, #5, #6, #7, #8, #9, #11, #13, #14, #15, #16, #20, #21, #22, #23, #29, #30, #35, #37, #43, #45, #46, #47, #48, #55, #61, #63, #64, #68, #70, #72, #74, #180, #181, and #182) on the secured unit. The facility census was 80.

Inspectors wroteBased on observation, interview, and policy review. the facility failed to ensure weekly skin assessments were being completed thoroughly. This affected one resident (#71) of three residents reviewed for skin issues. Additionally, the facility failed to ensure treatments were completed as ordered and an order for suture removal was completed. This affected two residents (#23 and #29) of three residents reviewed for skin. The facility census was 80.

Inspectors wroteBased on observation, review of the facility policy, record review, resident interview, and staff interview, the facility failed to provide appropriate treatments and services for residents with indwelling catheters. This affected one resident (#130) out of three residents reviewed for indwelling catheters. The facility census was 80.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to provide pain medication for a resident per physician orders. This affected one resident (#33) out of five residents reviewed for medications. The facility census was 80.

Inspectors wroteBased on resident interview, staff interview, and test tray, the facility failed to serve palatable meals. This affected two residents (#57 and #60) of two residents reviewed for meals. The facility was 80.

Inspectors wroteBased on record review, observations staff and resident interviews and policy review the facility failed to ensure a residents dressing changes were completed per physician orders. This affected one (#20) out of three residents reviewed for skin breakdown. The facility census was 70.

Inspectors wroteBased on record review, review of a medication error report, staff interview and policy review, the facility failed to ensure medications were transcribed and administered per the physician's order. This affected one (#20) out of three residents reviewed for medication administration. The facility census was 70.

Inspectors wroteBased on observation, record review, staff interview and policy review, the facility failed to ensure residents received medication per the physician's orders resulting in three medication errors out of 25 opportunities or a 12 percent (%) medication error rate. This affected one (#32) out of two residents observed for medication administration. The facility census was 70.

Inspectors wroteBased on observation, review of the Local Health Department Inspection, review of the dishwasher temperature logs, review of the dishwasher manufacture recommendations, and staff interviews, the facility failed to ensure the dishwasher was at a temperature to properly sanitize dishes. This had the potential to affect all 70 residents who received food from the kitchen. The facility identified two residents who do not receive food from the kitchen. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, and review of policy, the facility failed to ensure the medical record contained accurate documentation regarding resident monitoring. This affected one (#14) of three residents reviewed for monitoring. The facility census was 67.

Inspectors wroteBased on medical record review, policy review, local police detective interview, staff interviews, family interview, review of local newspaper article, and review of the Self-Reported Incident reporting website, the facility failed to timely report to the state agnecy allegations of mistreatment/neglect of a resident. This affected one (#1) of six residents reviewed for potential mistreatment/neglect. The current census is 69.

Inspectors wroteBased on medical record review, policy review, local police detective interview, staff interviews, family interview, review of local newspaper article, and review of the Self-Reported Incident reporting website, the facility failed to investigate allegations of mistreatment/neglect of a resident. This affected one (#1) of six residents reviewed for potential mistreatment/neglect. The current census is 69.

Inspectors wroteBased on medical record review, policy review and staff interview, the facility failed to ensure the medical records contained the name of the nurse who provided care and all assessments contained accurate information. This affected two (#1 and #4) residents of four resident medical records reviewed for accuracy. The current census is 69.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Dietary Manager #232 had proper Safe Serve credentials. This had the potential to affect 73 residents who received meals from the kitchen. The facility census was 75.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents' Minimum Data Set (MDS) assessments were accurate. This affected six (#7, #32, #41, #53, #63, and #71) of 26 residents reviewed for MDS assessment accuracy. The facility census was 75.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure the care plan accurately reflected the care of five residents (#45, #53, #44, #41, and #73) out of five residents reviewed for accuracy of the care plan. The facility census was 75.

Inspectors wroteBased on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure the appropriate/required members of the interdisciplinary team (IDT) were invited to participate in the care planning process. This affected five residents (#7, #31, #44, #53, and #73) of five residents reviewed for care planning. The facility census was 75.

Inspectors wroteBased on medical record review and staff interview the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) form prior to discharge. This affected one resident (#129) out of three residents reviewed for NOMNC notification. The facility census was 75.

Inspectors wroteBased on resident record review, staff interview, and policy review, the facility failed to notify the resident/resident representative in writing of the reason for transfer/discharge to the hospital. Additionally, the facility failed to notify the ombudsman of the resident's transfer/discharge to the hospital. This affected one (#76) of one resident reviewed for hospitalization. The census was 75.

Inspectors wroteBased on resident record review, staff interview, and policy review; the facility failed to notify the resident/resident representative of the facility's bed hold policy when a resident was transferred to the hospital. This affected one (#76)) of one resident record reviewed for hospitalization. The census was 75.

Inspectors wroteBased on medical record review, resident and staff interviews, and review of facility policy, the facility failed to provide timely follow-up appointments and implement a treatment plan to include wound vac as ordered by the physician. This affected one resident (#58) of one resident reviewed for out of facility appointments and one resident(#73) of one resident reviewed for functional wound treatment equipment. The census was 75.

Inspectors wroteBased on resident record review and staff interview, the facility failed to timely notify the physician of abnormal laboratory results. This affected one (#7) of three residents reviewed for urinary tract infection. The census was 75.

Inspectors wroteBased on observation, medical record review, staff interview, review of a facility policy, and review of guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure unvaccinated residents were quarantined following readmission. This affected two (#73 and #277) of two residents reviewed after readmission to the facility. The census was 75.

Inspectors wroteBased on resident record review, staff interview, review of infection surveillance documentation, and review of facility policy, the facility failed to implement antibiotic stewardship protocol to ensure appropriate antibiotic use. This affected one resident (#7) of three residents reviewed for urinary tract infection. The census was 75.