Liberty Retirement Community of Lima Inc

Inspectors wroteBased on employee file review, interview, and review of the employee handbook, the facility failed to ensure performance evaluations were completed as required. This affected four (#146, #166, #300, and #304) of four Certified Nursing Assistants (CNAs) reviewed for performance evaluations. This had the potential to affect all 51 residents residing in the facility. The facility census was 51.

Inspectors wroteBased on infection log review, staff interviews, and policy review, the facility failed to ensure an appropriate Antibiotic Stewardship Program was established as required. This had the potential to affect all 51 residents who reside in the facility. The facility census was 51.

Inspectors wroteBased on review of the state nurse aide registry, review of electronic mail (email) communications, review of the facility working schedules, review of employee time sheets, observations, staff interviews, and policy review, the facility failed to ensure staff were not working in the facility with abuse findings in the stated nurse aide registry. This had the potential to affect 15 (#16, #17, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) residents that reside on [NAME] and [NAME] hallways. The facility census was 51.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure the proper storage of medications. This had the potential to affect 15 (#16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) residents residing on [NAME]/[NAME] hallways and 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #49, #50, #51, #52) residents residing on the Tuscan East hallway. The facility census was 51.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure a homelike environment regarding pervasive odors. This had the potential to affect 17 (#32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, and #48) residents residing on the Tuscan [NAME] hallway. The facility census was 51.

Inspectors wroteBased on record review, observation, resident and staff interviews, and policy review, the facility failed to ensure a resident's call light was in reach. This affected one (#50) of 10 residents reviewed for call light placement. The facility census was 51.

Inspectors wroteBased on record review, staff and physician interviews, and policy review, the facility failed to ensure the physician was notified of laboratory results in a timely manner. This affected one (#54) of three resident reviewed for lab results. The facility census was 51.

Inspectors wroteBased on record review, review of a fall investigation, review of a facility self-reported incident (SRI), and staff interview, the facility failed to ensure that adequate supervision was provided on night shift. This affected one (#9) of three residents reviewed for falls. The facility census was 51.

Inspectors wroteBased on record review, review of a facility self-reported incident (SRI), staff interviews, and policy review, the facility failed to ensure medications were administered as ordered. This affected two (#37 and #9) of three residents reviewed for medication administration. The facility census was 51.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure medications were administered as ordered resulting in two medication errors out of 31 opportunities or a 6.25 percent (%) medication error rate. This affected one (#25) of three residents observed during medication pass. The facility census was 51.

Inspectors wroteBased on observation, record review, Emergency Medical Services (EMS) report review, hospital documentation review, death certificate review, resident interview, staff interview, review of facility's policy for Cardio-Pulmonary Resuscitation (CPR), and review of facility's policy and procedure for In Case of Decannulation, the facility failed to ensure the necessary life-sustaining respiratory services were provided to residents who required invasive mechanical ventilation via tracheostomy (a hole in the front of the neck and into the windpipe) cannula. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] at 1:40 A.M., when Resident #54 was found unresponsive without a pulse, with the tracheostomy cannula dislodged, and had been without oxygen for an unknown period of time. [...]

Inspectors wroteBased on review of the facility's assessment and staff interview, the facility failed to assess the staffing needed to ensure resident receive the necessary care and treatment in the annual facility assessment. This has the potential to affect all 47 residents residing in the facility. The current census is 47.

Inspectors wroteBased on medical record reviews, observations, resident interview, staff interview, review of Tuberculosis (TB) Risk Assessment, and review of policy, the facility failed to properly handle soiled linen for Resident #3. In addition, the facility failed follow enhanced barrier precautions for Residents #39 and #40. The facility failed to complete the TB risk assessment annually. This had the potential to affect all 47 residents. The facility census was 47.

Inspectors wroteBased on medical record review, census list review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents were provided a clean and sanitary environment. This directly affected Resident #3 and potentially 14 additional residents (#2, #4, #9, #12, #13, #17, #21, #25, #33, #34, #35, #40, #42, #49) who resident on the same hall as Resident #3. The facility census was 47.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, resident food list review, and review of facility policy, the facility failed to ensure resident meals were free from choking hazards. This affected Resident #34 with the potential to affect an additional seven (#3, #4, #8, #15, #21, #41, and #46) residents who were served soup. In addition, the facility failed to ensure the facility followed the fall policy and provided documentation of the fall in the medical record. This affected one (#6) of seven residents reviewed for falls. The facility census was 47.

Inspectors wroteBased on medical record review, observation, staff interview, review of manufacturer instructions, and review of facility policy the facility failed to administer medications per physician order and administer ophthalmic drugs as recommended. This affected two (#22 and #24) of four residents reviewed for medication administration. The facility census was 47.

Inspectors wroteBased on record review, resident and staff interviews, and policy review, the facility failed to ensure staff notified the physician and family representatives of residents' changes in condition. This affected two (#24 and #51) of two residents reviewed for notification. The current census is 47.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were free from physical restraint. This affected one (#30) of one resident reviewed for phyiscal restraint. The facility census was 47.

Inspectors wroteBased on review of medical records, staff interview, and review of facility policy, the facility failed to have documentation of a resident's discharge disposition in the medical record. This affected one (#53) of three closed records reviewed for discharge. The census was 47.

Inspectors wroteBased on record review and staff interview, the facility failed to document a resident's discharge information in the medical records including appropriate information for a resident's discharge to a hospital. This affected one (#56) of six residents reviewed for discharges. The current census is 47.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to develop a comprehensive person care plan related to skin impairment. This affected one (#10) of three residents reviewed for skin breakdown. The facility census was 47.

Inspectors wroteBased on medical record review, observations, staff interview, and policy review, the facility failed to provide activities to meet the resident's needs and cognitive capabilities. This affected one (#40) of three residents reviewed for activities. The facility census was 47.

Inspectors wroteBased on medical record reviews, observation, and staff interviews, the facility failed to continually assess a surgical wound and schedule recommended follow up wound clinic appointments for Resident #02; failed to ensure accurate assessment of skin impairment and initiate treatment timely for a rash for Resident #10; and the facility failed to document the cause of wound injury/trauma area for Resident #51. This affected three (#02, #10, and #51) of four residents reviewed for skin assessments and treatments. The facility census was 47.

Inspectors wroteBased on the medical record review, hospital report review, staff interview and policy reviews, the facility failed to ensure the necessary care and treatment was provided when a resident with a urinary catheter displayed symptoms of a urinary tract infection (UTI). This affected one (#51) out of two residents reviewed for care and treatment of urinary catheters. The facility census was 47.

Inspectors wroteBased on review of medical records and staff interview, the facility failed to ensure residents were assessed by a physician within the first 30 days after admission. This affected one (#28) of three residents reviewed for physician visits. The census was 47.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to ensure an appropriate and timely response to the pharmacist drug regimen reviews. This affected two (#02 and #04) residents out of the five residents reviewed for pharmacy reviews. The facility census was 47.

Inspectors wroteBased on review of medical records, staff interviews, and review of facility policy, the facility failed to have a justified use of an antibiotic. This affected two (#39and #40) of two residents reviewed for antibotics. The census was 47.

Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to ensure residents were free from significant medications errors. This affected four (#3, #10, #51 and #53) residents out of five residents reviewed for medication administration. The facility census was 47.

Inspectors wroteBased on observation, staff interviews, and review of facility policy, the facility failed to ensure insulin multi-use vials were dated. This affected two residents' (#4 and #25) insulin vials observed in a medication cart. The facility also failed to ensure multi-dose insulin vials were discarded 28 days after the opened date. This affected one resident's (#12) insulin vial observed a medication cart. The facility also failed to ensure medications were stored in their original containers. This affected one medication cart of two observed. The census was 47.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to notify the physician of an abnormal laboratory (lab) results timely. This affected one (#51) resident of one residents reviewed for laboratory test. The facility census was 47.

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure residents received dental services. This affected one (#34) of two residents reviewed for dental service. The facility census was 47. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, heart failure, type two diabetes mellitus without complications, hypothyroidism, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 12/07/25, revealed the resident was cognitively intact. Review of the care plan, revised on 05/12/25, revealed Resident #34 had potential for oral/dental health problems due to poor oral hygiene. [...]

Inspectors wroteBased on medical record review, resident interview, staff interview, review of meal ticket, and review of facility policy revealed Resident #4 did not receive food items per preference. This affected one (#4) of four residents reviewed for nutrition. The facility census was 47.

Inspectors wroteBased on review of the medical record, observation, staff interview, and review of facility policy, the facility failed to provide adaptive eating utensils. This affected one (#4) of one resident reviewed for adaptative equipment. The facility census was 47.

Inspectors wroteBased on record review, resident, family, and staff interview and review of facility policy, the facility failed to timely treat and assess the resident's pressure wounds. This affected two Residents (#10 and #12) of three residents reviewed for wounds. The facility census was 43.

Inspectors wroteBased on record review, pharmacy staff interview, facility staff interview, and review of facility policy, the facility failed to ensure residents were administered as physician ordered, resulting in a significant medication error. This affected one (Resident #10) of one resident reviewed for medication administration. The facility census was 43.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents were provided meals according to their preferences. This affected two residents (#20 and #21) of three residents reviewed for meal service. The facility census was 42.

Inspectors wroteBased on review of records, facility policy and staff interviews, the facility failed to accurately document and treat wounds. This affected one (#10) of three residents reviewed. The facility census was 46.

Inspectors wroteBased on review of records, facility policy and staff interviews, the facility failed to accurately document and treat pressure wounds. This affected one (#10) of three residents reviewed. The facility census was 46.

Inspectors wroteBased on review of personnel files, review of facility documentation, and staff interviews, the facility failed to employ a qualified dietary manager. This affected all residents who received food from the kitchen. The facility identified two residents (#24 and #48) who did not receive food by mouth. The facility census was 51.

Inspectors wroteBased on observation, staff interview, review of the dishwasher manual, review of the dishwasher temperature log, and policies review, the facility failed to appropriately store food and ensure the dishwasher was sanitizing. This had the potential to affect all residents who received food from the kitchen. The facility identified two (#24 and #48) residents who do not receive food by mouth. The facility census was 51.

Inspectors wroteBased on staff interviews, observations, review of Legionella Water Management Plan, and the review of policy, the facility failed to ensure procedures were followed for Legionella prevention and ensure staff properly transported soiled lines in common areas. This had the potential to affect all 51 residents. The census was 51.

Inspectors wroteBased on observation, staff interview, ombudsman interview, family interview, and policy review the facility failed to ensure pungent smells of urine did not permeate into common areas and dining room. This had the potential to affect all residents. The facility census was 51.

Inspectors wroteBased on observation, resident diet list review, resident interview, resident representative interview, staff interviews, and review of policies, the facility failed to provide residents a dignified dining experience. This had the potential to affect all residents except 15 residents (#1, #3, #6, #18, #23, #24, #27, #30, #32, #34, #37, #41, #47 #48, and #198) who did not receive food by mouth and residents with a puree or mechanical soft diet. The facility census was 51.

Inspectors wroteBased on observation, medical record review, resident family interview, staff interview, review of the activities calendar, review of the facility brochure, and review of policy, revealed the facility failed to provide appropriate and engaging activities in the memory care unit. This affected five residents (#20, #30, #36, #38, and #43) were reviewed with the potential to affect an additional five (#3, #24, #31, #32, and #34) residents in the memory care unit. The facility census was 51.

Inspectors wroteBased on review of the menu, observation, staff interview, review of census sheet, review of the dietary spreadsheet, and policy review, the facility failed to ensure menus were followed including offering appropriate substitutions for 12 (#5, #21, #28, #27, #33, #40, #42, #47, #197, #198, #199, and #243) residents and serving sizes for 10 (#3, #20, #24, #30, #31, #32, #34, #36, #38, and #43) residents. The facility census was 51.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and policy review, and facility policy the facility failed to reasonably accommodate a resident's requests. This affected one (#197) of one resident reviewed for choices. The census was 51.

Inspectors wroteBased on observation, record review, policy review and staff interviews, the facility failed to ensure code status documentation was addressed timely. This affected one (#247) of 19 reviewed for advanced directives. The facility census was 51.

Inspectors wroteBased on medical record review, observation, resident interview, nurse practitioner interview, staff interview, and policy review, the facility failed to implement interventions to prevent skin impairment timely for a resident with stage 4 pressure ulcers and ensure would measurements were completed upon readmission. This affected one (#197) of three residents reviewed for pressure ulcers. The facility census was 51.

Inspectors wroteBased on record review, observation, staff interview and policy review, the facility failed to provide adequate supervision for residents while they were smoking. This affected two (#1 and #6) of two residents reviewed for smoking. The facility identified five residents who smoke. The facility census was 51.

Inspectors wroteBased on medical record review, staff interview, and review of National Center for Biotechnology Information (NCBI) National Library of Medicine (NLM), the facility failed to monitor medication for potential side effects, toxicity and/or effectiveness. This affected one (#28) of five residents reviewed for unnecessary medications. The facility census was 51.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure laboratory (lab) test were completed per physician orders. This affected three (#10, #17 and #26) of five residents reviewed for laboratory test. The facility census was 51.

Inspectors wroteBased on review of the menu, observation, review of the recipe, and staff interview, the facility failed to ensure pureed foods were made of appropriate consistency. This affected two (#24 and #48) residents who the facility identified as receiving a pureed diet. The census was 51.

Inspectors wroteBased on resident interviews, staff interview, and observation, the facility failed to prominently post where state survey results were located for residents to view. This had the potential to affect all 51 residents. The facility census was 51.

Inspectors wroteBased on observation, staff interview, review of the facility kitchen cleaning schedule checklist, and review of the facility policy, the facility failed to maintain a clean and sanitary kitchen environment. This had the potential to affect 47 residents in the facility. Resident #8 received no food by mouth and thus no food from the kitchen. The facility census was 48.

Inspectors wroteBased on observation, resident interview, staff interview and policy review, facility failed to ensure residents were properly supervised while smoking and smoking aprons were applied as required. This affected three (#1, #10, and #37) of three reviewed for smoking. The facility failed to sure a resident was transferred safely with a mechanical lift. This affected one (#48) of one resident reviewed for transfers. The facility census was 47.

Inspectors wroteBased on record review, staff interview, resident interview and policy review, the facility failed to ensure a resident received showers per personal preference on shower days. This affected one (#13) of three residents reviewed for choices. The facility census was 47.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a resident was provided care and treatment to maintain foot health. This affected one (#35) of one resident reviewed for foot care. The facility census was 47.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure an antianxiety medication, which was ordered as needed (PRN), had an end date for use. The facility also failed to offer non-pharmacological interventions prior to administration of the PRN antianxiety medication. This affected one (#48) of the five residents reviewed for psychotropic medication use. The facility census was 47.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure timely wound culture was obtained per physician orders. This affected one (#35) of one resident reviewed for laboratory test. The facility census was 47.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to assess and provide rehabilitation services as ordered. This affected one (#203) resident of the two residents reviewed for rehabilitation services. The facility census was 47.