Lima Convalescent Home

In the surveyor’s words

From the most serious findings on record at Lima Convalescent Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF726Jul 30, 2026

  Based on review of personnel files, staff interviews, and review of facility policy the facility failed to ensure Certified Nursing Assistants (CNA) had documented competency in skills and techniques to meet the residents' needs. This had the potential to affect all residents. The facility census was 65.Findings include:Review of Certified Nursing Assistant (CNA) #201's personnel file revealed a hire date of 05/28/26. The contents of the personnel file was absent of a CNA checklist demonstrating competency in skills and techniques. Review of CNA #202's personnel file revealed a hire date of 01/28/26. The contents of the personnel file was absent of a CNA checklist demonstrating competency in skills and techniques. Review of CNA #203's personnel file revealed a hire date of 01/23/26. […]

• No harm, potential for more than minimal, widespreadF812Apr 24, 2025

  Based on observation, staff interview, and facility policy review, the facility failed to ensure food preparation and storage was maintained. This had the potential to affect all residents. The facility census was 66. Findings include: Observation during initial kitchen tour on 04/21/25 between 8:20 A.M. to 8:40 A.M. revealed the stand-up freezer had one bag of French fries and one bag of chicken that were opened, unsealed, unlabeled, and undated, the walk-in freezer had two stacks of boxes sitting on the floor of the freezer. The two stacks contained the following food: four boxes were [NAME] frozen cakes and one box of wild caught cod. Concurrent observation revealed [NAME] #201 who prepared and served breakfast was not wearing a hat or hairnet, or hairnet covering his full beard. […]

• No harm, potential for more than minimal, widespreadF880Apr 24, 2025

  Based on observation, staff interview, review of facility Legionella control measures, and policy review, the facility failed to follow facility control measures for Legionella. This had to potential to affect all resident residing in the facility. Additionally, the facility failed to follow infection prevention procedures during wound care observation. This affected one resident (#8) of two residents observed for wound care dressing change. The facility census was 66. Findings include: 1. Review of the facility's Legionella control measures revealed the facility would obtain resident room water temperatures. Further review of the facility's control measures revealed no empty resident rooms or shower room water flushes if a room is unoccupied. […]

• No harm, potential for more than minimal, patternF656Apr 24, 2025

  Based on record review, staff interviews, and facility policy, the facility failed to ensure care plans were accurate. This affected four (#8, #9, #26, #54) of 23 residents reviewed for care planning. The facility census was 66. Findings include: 1. Review of medical record for Resident #8 revealed admitted [DATE] with diagnoses including diabetes mellitus, dehydration, depression, non-pressure chronic ulcer of lower leg, and chronic osteomyelitis of her right ankle and foot. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had intact cognition and required extensive one person assistance for bed mobility, transfers, limited assistance with toileting and supervision for eating. […]

• No harm, potential for more than minimal, patternF558Aug 15, 2022

  Based on observations, resident and staff interviews and policy review, the facility failed to accommodate resident needs by ensuring the resident's call lights were within reach. This affected four (#24, #30, #34, and #122) out five residents sampled for accessibility of call lights. Facility census was 71. Findings include: Observation on 08/08/22 at 4:55 P.M. revealed Resident #122 was sitting up in bed with her dinner tray in front of her. Resident #122 stated she did not like what they served her for dinner. When asked if she had told staff she stated she couldn't tell staff due to no being able to reach her call light. […]