Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and interview with a resident, staff and Ombudsman, the facility failed to ensure a
resident was treated with respect and dignity when the administration issued the resident an unofficial
(fake) 30 day discharge notice. This affected one (#44) of 27 residents reviewed during the survey. The
census was 131.
Findings include:
Review of the medical record for Resident #44 revealed the resident was admitted to the facility on [DATE].
Diagnoses include borderline personality disorder, cerebral infarction, malignant neoplasm of rectum,
hemiplegia and hemiparesis, dysphagia, obstructive sleep apnea, diabetes mellitus type two, bacteremia,
neuromuscular dysfunction of the bladder, cystectomy, and gastrostomy.
Review of a care plan dated 11/29/19, revealed Resident #44's goal was to discharge home. Review of a
care plan dated 03/06/19, revealed the resident had a mood problem related to admission to the facility,
depression, anxiety, and borderline personality disorder. The goal was for the resident to have improved
mood state as evidenced by happier/calmer appearance and no signs or symptoms of depression, anxiety,
and or sadness.
Review of the quarterly minimum data set assessment (MDS) assessment target date 07/02/19, revealed
Resident #44 had intact cognition. The resident required extensive assistance of two people for bed mobility
and personal hygiene. Resident #44 was totally dependent of two people for transfers and toilet use.
Review of the 30 day discharge notice dated 06/27/19, revealed a 30 day discharge notice was given to
Resident #44. The discharge notice revealed due to circumstances, the resident would be discharged on
07/28/19. The proposed location to which Resident #44 would be discharged to was another skilled nursing
facility. The circumstances for the 30 day discharge notice was the safety of individuals in the home was
endangered. Review of the 30 day discharge notice further revealed there was no information contained
within the notice that it was not an actual discharge notice and/or a fake notice.
Interview on 08/13/19 at 7:37 A.M. with the Administrator revealed there was a concern when Resident #44
told a nurse he/she was going to cut a secure care bracelet off of another resident in order for the other
resident to be able to go outside. The Administrator revealed Resident #44 was told by the Administrator if
Resident #44 was going to try to put another resident in harms way, the facility would have to issue a 30
day discharge notice. The Administrator revealed a 30 day discharge notice was filled out by the
Administrator and given to Resident #44. The Administrator further revealed
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
365361
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Shawnee Manor
2535 Fort Amanda Road
Lima, OH 45804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the copy of the 30 day discharge notice was given to Resident #44 so the resident would understand what
a discharge notice would look like. The Administrator revealed the 30 day notice was not submitted to the
state department or to the Ombudsman's office because it was not an official 30 day discharge notice.
Interview on 08/13/19 at 8:54 A.M. with Resident #44 revealed the Administrator gave the resident a
discharge notice. The resident reported she/he was told by the Administrator that the document was his/her
notice of discharge and she/he would have to leave the facility. The resident revealed it was discovered that
the 30 day discharge notice was not an official notice when a meeting was held with the Ombudsman.
Resident #44 revealed when the resident was given the discharge notice it caused the resident to panic
related to not knowing what would happen or where to go.
Interview on 08/13/19 at 2:10 P.M. with the Ombudsman revealed during a meeting the Ombudsman had
with the Administrator on 06/24/19, the Administrator reported a 30 day discharge notice was given to
Resident #44, but it was not a true discharge notice and that it was just given to the resident as an example
of what could happen. The Ombudsman revealed Resident #44 was assessed twice by another skilled
nursing facility looking to admit the resident. The Ombudsman further revealed multiple boxes for packing
were observed in the residents room in preparation of a discharge.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365361
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Shawnee Manor
2535 Fort Amanda Road
Lima, OH 45804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review and staff interview, the facility failed to ensure a Quarterly Minimum Data
Set (MDS) assessment was submitted within 14 days of completion to Center for Medicare & Medicare
Services (CMS) system. This affected one (#2) out of 27 resident MDS assessments reviewed during the
annual survey. The facility census was 131.
Residents Affected - Few
Findings include:
Review of medical record for Resident #2 revealed an admission date of 06/21/16 with diagnoses including
muscle weakness, history of falls, dementia without behavioral disturbances, pulmonary heart disease,
orthostatic hypotension, seizures, anxiety, essential hypertension and major depressive disorder.
Review of Quarterly MDS with an assessment reference date (ARD) of 07/02/19 documented the
assessment was completed.
Review of electronic medical record revealed Resident #2 MDS assessment was never transmitted to CMS
system as of 08/14/19.
On 08/14/19 at 9:22 A.M. interview with MDS Nurse #600 verified Resident #2's Quarterly MDS
assessment with an ARD of 07/02/19 was completed but was not submitted timely within 14 days of the
completion as required. She further revealed it was due to the facility's electronic medical record MDS
assessment form because it pre-populates a response of the facility is not a Medicare certified facility. She
verified it was an over site of not changing the response so it was never submitted to CMS upon being
completed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365361
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Shawnee Manor
2535 Fort Amanda Road
Lima, OH 45804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, resident and staff interview and policy review, the facility failed to
implement adequate measures to ensure residents followed safe smoking procedures. This affected two
residents (#38 and #62) of two residents reviewed for smoking. The facility identified eight residents as
smokers. Facility census was 131.
Findings include:
1. Review of Resident #38's medical record revealed an admission date of 07/28/11 with diagnoses of
folate deficiency, alcohol use with induced psychotic disorder, osteoarthritis, gait and mobility abnormalities,
unsteady on feet, muscle weakness, hyperlipidemia, major depressive disorder, atrial fibrillation, cardiac
pacemaker, dementia without behaviors, epiphora, dry eye syndrome, ectropion of unspecified eye, lack of
coordination, age related cataract, allergic conjunctivitis, dorsalgia, constipation, abnormal posture, chronic
pain, hypertension, neoplasm of breast, gastroesophageal reflux disease and cardiac arrhythmias.
Review of Resident #38's plan of care dated 11/08/13 revealed the resident was a smoker and the goal was
for the resident to be free from injury related to smoking. Interventions included assessing the resident's
ability to smoke safely, obtain a physician order and consent and the resident was to smoke at established
facility smoking times and locations.
Review of Resident #38's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident
had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment.
Review of a physician order dated 09/21/17 revealed Resident #38 may smoke per facility policy.
Review of the smoking assessment dated [DATE] revealed Resident #38 could light her own cigarette,
required supervision, required the facility to store lighter and cigarettes, and a plan of care was to be used
to assure resident safety while smoking.
Interview on 08/12/19 at 11:09 A.M. with Resident #38 confirmed having cigarettes and a lighter on person.
Interview on 08/12/19 at 5:05 P.M. with State Tested Nurse Aide (STNA) #430 and Corporate Nurse #420
confirmed the smoking assessment indicated Resident #38 was to be a supervised smoker and that the
facility is to store lighter and cigarettes.
Interview and observation on 08/12/19 at 5:08 P.M. with STNA #430 confirmed Resident #38 to have a pack
of cigarettes and a lighter in her possession. The items were confiscated from the resident and secured
with nursing staff. STNA #430 instructed the resident she would have to request the smoking items at the
designated facility smoke times.
2. Review of Resident #62's medical record revealed an admission date of 09/09/17 with diagnoses of
aftercare following joint replacement surgery, dysphagia, muscle weakness, unsteadiness on feet,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365361
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Shawnee Manor
2535 Fort Amanda Road
Lima, OH 45804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
unspecified severe protein calorie malnutrition, lack of coordination, fracture of the left humerus, adult
failure to thrive, vitamin D deficiency, anxiety disorder, cognitive communication deficit, difficulty walking, left
hand contracture, contracture left upper arm, congestive heart failure, gait and mobility abnormalities, open
angle glaucoma, major depressive disorder, history of urinary tract infections, neuromuscular dysfunction of
bladder, hypertension, aortic valve stenosis, hypothyroidism, gastroesophageal reflux disease,
osteoarthritis and repeated falls.
Review of the smoking assessment dated [DATE] revealed Resident #62 could not light her own cigarette,
required supervision, required the facility to store lighter and cigarettes, and a plan of care was to be used
to assure the resident was safe while smoking.
Review of Resident #62's plan of care dated 04/25/19 revealed the resident to be a smoker. Interventions
included being free from injury related to smoking, assessing the resident's ability to smoke safely, smoking
at established facility smoking times and locations and obtaining a physician's order and consent.
Review of a physician order dated 06/24/19 revealed Resident #62 may smoke per facility policy.
Review of Resident #62's MDS 3.0 assessment dated [DATE] revealed the resident had a BIMS score of
six indicating severe cognitive impairment.
Interview and observation on 08/12/19 at 4:25 P.M. with Resident #62 revealed the resident to confirm
having a pack of cigarettes and a lighter in her purse and in her possession. Resident #62 reported utilizing
a black rubber ash tray which was observed sitting on her bedside table with a cigarette butt in it.
Interview on 08/12/19 at 5:05 P.M. with STNA #430 and Corporate Nurse #420 confirmed the smoking
assessment dated [DATE] revealed Resident #62 was to be a supervised smoker and that the facility was to
store her lighter and cigarettes.
Interview and observation on 08/12/19 at 5:10 P.M. with STNA #430 confirmed Resident #62 to have a pack
of cigarettes and a lighter in her possession and a black rubber ash tray sitting on her bedside table. The
items were confiscated from the resident and secured with nursing staff. STNA #430 instructed the resident
she would have to request the smoking items at the designated facility smoke times.
Review of the facility policy titled, Smoking Policy dated 05/09/17 revealed smoking privileges will be
addressed in the care plan, residents must be accompanied by staff, family or properly trained volunteers
while smoking, smoking materials will be kept in a designated area accessible only by staff and ashtrays
will be constructed of metal per regulations set by the National Fire Safety Agency.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365361
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Shawnee Manor
2535 Fort Amanda Road
Lima, OH 45804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and staff interview, the facility failed to ensure cleanliness of the microwave ovens.
This had the potential to affect all 21 residents (#8, #20, #23, #26, #28, #31, #33, #34, #41, #46, #59, #63,
#74, #85, #100, #104, #107, #113, #127, #128, and #131) residing on the secured unit. The facility census
was 131.
Findings include:
Observation during tour of the secured unit dining area on 08/14/19 at 8:30 A.M. revealed there was
multiple dried splattered substances noted on the inside of the microwave oven that was sitting on the
counter.
Interview with the Director of Nursing (DON) on 08/14/19 at 8:30 A.M. at the time of the observation
confirmed the multiple dried splattered substances on the inside of the microwave oven and confirmed it
was in need of cleaning. The DON reported this is generally a task completed by the State Tested Nurse
Aids (STNA's) assigned to work the secured unit. The facility confirmed there are 21 residents (#8, #20,
#23, #26, #28, #31, #33, #34, #41, #46, #59, #63, #74, #85, #100, #104, #107, #113, #127, #128, and
#131) that could utilize the microwave oven and that could potentially be affected.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365361
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Shawnee Manor
2535 Fort Amanda Road
Lima, OH 45804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observations, staff interviews and review of a cleaning schedule, the facility failed to maintain
resident care equipment and wheelchairs were maintained in a clean manner. This had the potential to
affect one (#09) resident who had a wheelchair that was soiled, four residents (#22, #73, #83 and #333) in
the B and D halls who require the assistance of the stand up assist lift, nine residents (#11, #45, #76, #97,
#98, #103, #105, #107 and #123) in the D hall who require the mechanical lift and 18 residents (#5, #10,
#19, #32, #36, #38, #48, #49, #62, #65, #69, #96, #90, #99, #112, #120, #124 and #126) in the E hall who
use the shower chairs. The facility census was 131.
Findings include:
Observations on 08/12/19 at 2:08 P.M. and on 08/13/19 from 8:14 A.M. to 1:41 P.M. revealed the shower
chairs in the E hall appeared to have foreign substances on the seat and on the legs. The B hall shower
room contained a stand up lift assist with foreign substances on the foot pad and on the soft knee pads. A
wheelchair in the AB lounge had a large amount of foreign substances on the back part as well as two pair
of tennis shoes. The stand up lift assist and the mechanical lift in the D hall shower room were also soiled
with foreign substances.
Interview on 08/13/19 at 1:00 P.M. with Licensed Practical Nurse (LPN) #405 provided verification of the
soiled shower chairs in the E hall shower room.
Interview on 08/13/19 at 1:10 P.M. with Environmental Service Supervisor (ESS) #400 provided verification
of the soiled stand up lift assist in the B hall shower room. ESS #400 further added it is the State Tested
Nursing Assistants responsibility to ensure the resident care equipment is cleaned.
Interview on 08/13/19 at 1:28 P.M. with the Assistant Director of Nursing (ADON) #410 provided verification
of the wheelchair in the AB lounge being soiled and having two pair of shoes on the seat. ADON #410
identified the wheelchair as belonging to Resident #09 and has not been used since Resident #09 went on
hospice. ADON #410 was could not give an exact date Resident #09 last used the wheelchair.
Interview on 08/13/19 at 3:46 P.M. with the Director of Nursing and ADON #410 revealed the facility does
not have a policy on cleaning the resident care equipment and wheelchairs. ADON #410 further added no
documentation could be located indicating last cleaning of the wheelchairs or resident care equipment. The
facility confirmed the deficient practice had the potential to affect one (#09) resident who had a wheelchair
that was soiled, four residents (#22, #73, #83 and #333) in the B and D halls who require the assistance of
the stand up assist lift, nine residents (#11, #45, #76, #97, #98, #103, #105, #107 and #123) in the D hall
who require the mechanical lift and 18 residents (#5, #10, #19, #32, #36, #38, #48, #49, #62, #65, #69,
#96, #90, #99, #112, #120, #124 and #126) in the E hall who use the shower chairs
Review of the Wheelchair Cleaning Schedule by Rooms form, undated, revealed the wheelchair for
Resident #09 was to be cleaned on Thursdays.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365361
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the August 15, 2019 survey of SHAWNEE MANOR?
This was a inspection survey of SHAWNEE MANOR on August 15, 2019. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SHAWNEE MANOR on August 15, 2019?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.