Liberty Retirement Community of Lima Inc

In the surveyor’s words

From the most serious findings on record at Liberty Retirement Community of Lima Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Mar 19, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF730Jul 27, 2026

  Based 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. Findings include: Review of employee file for CNA #146 revealed a hire date of 05/23/25. No performance evaluations were located in the file. Review of employee file for CNA #166 revealed a hire date of 06/19/24. No performance evaluations were located in the file. Review of employee file for CNA #300 revealed a hire date of 03/05/26. No 90 day performance evaluation was located in the file. […]

• No harm, potential for more than minimal, widespreadF881Jul 27, 2026

  Based 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. Findings include: Review of infection control log for May 2026 and June 2026 revealed that the facility did not use McGeers criteria for infections to determine if antibiotics were necessary or justified. Interview on 07/15/26 at 2:39 P.M. with Infection Preventionist (IP #206) revealed that if an infection is not cultured she only goes by what the physician ordered. IP #206 verified they do not use McGeers criteria at this facility. […]

• No harm, potential for more than minimal, widespreadF838Mar 19, 2026

  Based 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. Findings include: Review of the facility assessment updated March 2026 revealed no staffing levels were included in the assessment. The facility assessment did not contain any documented information on staffing levels to ensure that there are a sufficient number of staff with appropriate competencies and skill sets necessary to care for residents' required care. […]

• No harm, potential for more than minimal, widespreadF880Mar 19, 2026

  Based 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.Findings include:1. Review of the medical record revealed Resident #3 was admitted on [DATE]. […]