Inspection·December 19, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to provide two residents, #25 and #40, of five (#25, #40, #63, #67, and #80) reviewed for showers, with showers twice weekly. The facility census was 126. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #25 revealed an admission date of 01/06/21. Diagnoses include disorders of bladder, repeated falls, dementia, and diabetes mellitus type II. Review of the quarterly minimum data set assessment dated [DATE] revealed Residents #25 was cognitively impaired and was dependent for personal hygiene. Review of the Certified Nursing Assistant (CNA) documentation revealed Resident #25 received a shower on 11/29/24, 12/02/24, and 12/13/24 for the past 30 days with one refusal on 12/16/24. 2. Review of the medical record of Resident #40 revealed an admission date of 11/01/17. Diagnoses include dementia. Review of the quarterly minimum data set assessment dated [DATE] revealed Residents #40 was severely cognitively impaired and was dependent for all activities of daily living. Review of the CNA documentation revealed Resident #25 received a shower on 11/26/24, 12/17/24 for the past 30 days. Interview on 12/19/24 at 8:00 A.M. with Director of Nursing provided verification the showers were not documented as having been provided to the two residents. Review of the facility policy titled Activities of Daily Living, dated 04/29/16 stated the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and the plan of care. A resident who is unable to carryout activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00159551. 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 2 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 12/19/2024 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)