Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
Findings include:
1.Review of Medical Record for Resident #13 revealed admission date 01/25/22, with diagnoses including
chronic respiratory failure with hypoxia, dysphagia, hyperlipidemia, hypertension, generalized anxiety
disorder, chronic gout, depression, type two diabetes, and morbid obesity.
Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed brief interview of mental
status (BIMS) score of 14 which indicated cognitively intact. Resident required extensive assistance for
activities of daily living (ADL's).
Review of Care Plan dated 12/08/22 for Resident #13 revealed the resident had an ADL self-care
performance deficit related to chronic respiratory failure, dysphagia, obesity, hypertension, hypothyroidism,
anxiety, depression, and diabetes. Interventions include bathing/showering provide a sponge bath when a
full bath or shower cannot be tolerated, resident required assistance by staff with bathing/showering per
bath schedule and as necessary.
Review of shower sheet/skin check for Resident #13 from 02/01/23 through 04/09/23 revealed bed baths
were given instead of shower/whirlpool on 02/05, 02/08, 02/16, 02/20, 02/23, 03/02, 03/05, 03/08, 03/12,
03/15, 03/19, 03/22, 03/26, 03/29, 04/02, and 04/09. Resident received a shower/whirlpool on 02/01, 02/14,
and 02/27.
Interview on 04/18/23 at 9:43 A.M., with Resident #13 stated she does not get showers when she is
supposed to. Stated she gets washed up instead. Stated she was supposed to get a shower on Sunday and
did not. Stated the aid told her she would do it on Monday which also did not happen. Stated she had not
had her hair washed in two weeks. Resident stated she has never refused a shower.
Interview on 04/19/23 at 10:32 A.M., with Resident #13 stated she wanted a whirlpool bath today however,
the girl that came in stated she did not know how to do a whirlpool, so she received a complete bed bath
instead.
Further review of shower/skin check forms dated 04/19/23 for Resident #13 revealed resident received a
complete bed bath, and bed sheets were changed.
(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 11
Event ID:
365936
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
365936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Retirement Community of Lima Inc
2440 Baton Rouge Avenue
Lima, OH 45805
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Interview on 04/20/23 at 8:44 A.M., with Director of Nursing (DON) verified Resident #13 received bed
baths instead of showers/whirlpools on 02/05, 02/08, 02/16, 02/20, 02/23, 03/02, 03/05, 03/08, 03/12,
03/15, 03/19, 03/22, 03/26, 03/29, 04/02, and 04/09. Verified received bed bath on 04/19.
Review of policy titled Activities of Daily Living (ADL's), Supporting revised March 2018 revealed
appropriate care and services will be provided for resident who are unable to carry out ADL's
independently, with the consent of the resident and in accordance with the plan of care, including
appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).
Event ID:
Facility ID:
365936
If continuation sheet
Page 2 of 11
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
365936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Retirement Community of Lima Inc
2440 Baton Rouge Avenue
Lima, OH 45805
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 0687
Provide appropriate foot care.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
Findings include:
Review of medical record for Resident #35 revealed admission date of 12/16/20, with diagnoses including
schizoaffective disorder, bipolar type, anxiety, depression, and dementia with behavioral disturbances. The
resident remains in the facility.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely/never
understood with severely impaired cognition. She required extensive one person assistance for bed
mobility, transfers, eating toileting and personal hygiene.
Review of the care plan for actual impairment to skin integrity related to left second toe with drainage and
edema. Interventions included but were not limited to monitor and document size and treatment of skin
injury. Report failure to heal, signs and symptoms of infections to physician.
Review of progress note dated 04/06/23 revealed a wound to Resident #35's left second toe was noted on
04/03/23. The wound nurse assessed the wound which was described as the entire toe was edematous
with the base of the nail lifting upward, scant amount of serous drainage. The social worker was notified of
the need for a podiatry consult.
Review of a late entry progress note dated 04/12/23 documented the social worker was in the process of
obtaining another podiatrist consult because the facility podiatrist did not remove nails in house.
Review of progress note dated 04/13/23 revealed the wound nurse had been in to assess Resident #35,
her left second toe wound was documented as edematous, with base of nail lifting upward and a large
amount of purulent drainage. The social worker informed facility wound nurse Licensed Practical Nurse
(LPN) #544 of an outside podiatrist needed to be consulted.
Review of the physician orders revealed an order for a C-Reactive Protein (CRP) and wound culture.
Review of the CRP results dated 04/13/23 revealed it was less than 0.1 (within normal limits) milligrams per
liter (mg/L). There were no culture results in the electronic chart.
Review of progress note dated 04/18/23 revealed an outside podiatrist was contacted for referral but actual
insurance cards needed to be provided before an appointment would be made.
Interview on 04/18/23 at 4:31 P.M., with facility rounding wound LPN #544 revealed the left toe wound of
Resident #35 was discovered on 04/03/23. The physician was contacted and an order for an oral antibiotic
was given. The wound Certified Nurse Practitioner (CNP) #602 seen Resident #35 on 04/06/23 and
ordered a podiatry consult. The facility podiatrist was already scheduled to come to the facility on [DATE].
The second wound visit was 04/13/23 and staff had notified Wound LPN #544 insurance verification
needed to be provided before an appointment could be made. LPN #544 confirmed the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365936
If continuation sheet
Page 3 of 11
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
365936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Retirement Community of Lima Inc
2440 Baton Rouge Avenue
Lima, OH 45805
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 0687
consultation appointment had still not been made at the time of the interview.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/19/23 at 11:00 A.M., with Social Worker (SW) #587 revealed the facility podiatrist was
scheduled to provide services at the facility on 04/07/23. She was later informed the podiatrist would not
remove Resident #35's toenail in the house. She told the management she knew a podiatrist who may
come to the facility, and she would contact him, however he was out of state on vacation. SW #587 updated
the nurse and Administrator on 04/13/23, Resident #35 needed an outside podiatry appointment, explaining
she was responsible for the in-house ancillary appointments and the nurse was responsible for outside
appointments.
Residents Affected - Few
Interview on 04/20/23 at 7:32 A.M., with the Director of Nursing revealed the wound culture for Resident
#35 was picked up by the lab but was lost. She confirmed it was the responsibility of the facility to follow up
with orders to ensure they were resulted. She also confirmed the outside podiatrist consult was scheduled
for 04/24/23 was not made timely.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365936
If continuation sheet
Page 4 of 11
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
365936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Retirement Community of Lima Inc
2440 Baton Rouge Avenue
Lima, OH 45805
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 - Some
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, 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.
Findings include:
1. Review of medical record for Resident #1 revealed admission date 07/19/18, with diagnoses including
multiple sclerosis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, dysphagia,
chronic kidney disease, seizures, idiopathic progressive neuropathy, right foot drop, nicotine dependence
cigarettes, major depressive disorder, hypertension, and anxiety.
Review of Quarterly Minimum Data Set (MDS) assessment for Resident #1 dated 02/02/23 revealed brief
interview of mental status (BIMS) score of 13 which indicated cognitively intact. Resident required extensive
assist for activities of daily living (ADL's).
Review of Care Plan dated 01/26/23 for Resident #1 revealed resident is a smoker. Interventions included
resident had been assessed and requires supervision while smoking, instruct resident about smoking risks
and hazards and about smoking cessation aids that are available, observe clothing and skin for signs of
cigarette burns, smoking apron required while smoking, and resident is able to light own cigarette and hold
own cigarette.
Review of Smoking Safety Screen dated 03/31/23 for Resident #1 revealed resident required supervision
and smoking apron.
Interview on 04/17/23 at 7:54 P.M., with Resident #1 stated residents can go out to smoke by themselves.
Stated the nurse or aide give them their cigarettes and lighter before they go out.
2. Review of medical record for Resident #10 revealed admission date 01/19/22, with diagnoses including
hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and right dominant
side, peripheral vascular disease, type two diabetes, hyperlipidemia, adjustment disorder with mixed
anxiety and depressed mood, anorexia, insomnia, chronic obstructive pulmonary disease, and history of
falling.
Review of Quarterly MDS assessment dated [DATE] for Resident #10 revealed BIMS score of 15 which
indicated cognitively intact. Resident #10 required supervision for ADL's.
Review of Care Plan dated 03/27/23 for Resident #10 revealed resident is a smoker. Interventions included
resident required supervision while smoking and observe clothing and skin for signs of cigarette burns.
Review of smoking safety screen dated 03/31/23 for Resident #10 revealed resident is safe to smoke with
supervision.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365936
If continuation sheet
Page 5 of 11
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
365936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Retirement Community of Lima Inc
2440 Baton Rouge Avenue
Lima, OH 45805
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
Interview on 04/18/23 at 8:53 A.M., with Resident #10 stated staff do not go out with him when he smokes.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/19/23 at 10:21 A.M., with Resident #10 stated he has never burnt himself while smoking
even though his jacket shows otherwise.
Residents Affected - Some
Observation on 04/19/23 at 10:21 A.M., of Resident #10's jacket revealed several burn holes. Resident also
observed to have several holes in sweatpants which he stated were from his cat.
3. Review of medical record for Resident #37 revealed admission date 09/01/22, with diagnoses including
multiple sclerosis, trigeminal neuralgia, hypertension, hyperlipidemia, syndrome of inappropriate secretion
of antidiuretic hormone, neuromuscular dysfunction of bladder, urinary tract infection, cystostomy status,
urge incontinence, major depressive disorder, nicotine dependence, and cramp and spasm.
Review of Quarterly MDS assessment dated [DATE] for Resident #37 revealed a BIMS score of 14 which
indicated cognitively intact. Resident #37 required extensive assistance for ADL's.
Review of Care Plan dated 04/12/23 for Resident #37 revealed resident is a smoker. Interventions included
resident had been assessed and required supervision while smoking and observe clothing and skin for
signs of cigarette burns.
Observation on 04/19/23 at 11:07 A.M., of smoke break revealed six residents outside smoking. No
residents are noted to be wearing smoking aprons. Resident #1 is outside smoking. Resident #37 is noted
to have burn holes in blanket covering her lap. Resident #10 is noted to have burn holes in sweatshirt
jacket. Maintenance Director (MD) #566 is out with the residents. One resident dropped a cigarette on the
ground and asked the surveyor to pick it up. MD #566 was looking at door across the courtyard with back to
residents. MD #566 came over to pick up the cigarette for the resident, however, the resident had picked it
up himself. MD #566 relit resident's cigarette currently.
Interview on 04/19/23 at 11:17 A.M., with MD #566 of smoke break verified burn holes in Resident #37's
blanket covering her lap; verified burn holes in Resident #10's jacket; verified no residents were wearing
smoke aprons. MD #566 stated he was unsure if the facility had smoking aprons.
Interview on 04/19/23 at 12:20 P.M., with Director of Nursing (DON) verified the facility had smoking aprons.
DON stated the facility bases the need for smoke aprons on their smoking assessments. DON verified that
staff could stand inside the door to supervise smokers due to some staff being nonsmokers.
Interview on 04/19/23 at 1:28 P.M., with DON stated direct supervision would be outside with the residents
per facility policy.
Review of undated policy titled Resident Smoking Policy revealed smoking aprons and other safety devices
are provided for residents whose assessments showed they require them. Direct supervision will be
provided to residents who are assessed to need such supervision.
4. Review of medical record for Resident #48 revealed admission date of 03/28/23, with diagnoses
including end stage renal disease, chronic respiratory failure with hypoxia, Diabetes Mellitus with
neuropathy, and dependence on renal dialysis.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365936
If continuation sheet
Page 6 of 11
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
365936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Retirement Community of Lima Inc
2440 Baton Rouge Avenue
Lima, OH 45805
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 - Some
Review of the admission MDS assessments dated 04/01/23 revealed she was cognitively intact and
required extensive assistance with bed mobility, dressing, toileting, bathing and was dependent on staff for
transfers.
Review of Resident #48's activities of daily living care plan revealed she had a self-care deficit and
interventions included two-person assistance with mechanical lift for transfers.
Observation on 04/20/23 at 8:05 A.M., revealed State Tested Nursing Assistant (STNA) #506 was preparing
Resident #48 to be transferred out of bed with the mechanical lift. STNA #506 was the only staff member
present in Resident #48's room. Surveyor left room to allow care to be provided. At 8:08 A.M., observed
Resident #48's room door open. Surveyor entered room and observed Resident #48 sitting in geriatric
chair.
Interview on 04/20/23 at 8:09 A.M., with STNA #506 confirmed she transferred Resident #48 to her
geriatric chair utilizing the mechanical lift and did not have another staff member present when utilizing
mechanical lift for the transfer.
Interview on 04/20/23 at 8:10 A.M., with Licensed Practical Nurse (LPN) #512 stated staff are to use
two-person assist with mechanical lift transfers.
Interview on 04/20/23 at 9:43 A.M., with DON confirmed staff are to use two-person assistance with all
mechanical lift transfers.
Review of the policy Lifting Machine, Using a Mechanical last revised July 2017 revealed the guideline was
for at least two nursing assistants were needed to safely move a resident with a mechanical lift.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365936
If continuation sheet
Page 7 of 11
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
365936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Retirement Community of Lima Inc
2440 Baton Rouge Avenue
Lima, OH 45805
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
Review of the medical record for Resident #48 revealed an admission date of 03/28/23, with medical
diagnoses of end stage renal disease (ESRD), chronic respiratory failure, diabetes mellitus, anxiety, and
dependence upon dialysis.
Review of the medical record for Resident #48 revealed an admission Minimum Data Set (MDS)
assessment dated [DATE], which indicated Resident #48 was cognitively intact and required extensive
assist with bed mobility, dressing, toileting and was dependent upon staff for transfers. The MDS indicated
Resident #48 received two days of antianxiety medication.
Review of the medical record for Resident #48 revealed a physician order, dated 03/28/23, for Lorazepam
(antianxiety medication) tablet 1 milligram (mg), give one tablet by mouth every six hours PRN.
Review of the medical record for Resident #48 revealed a use of antianxiety medication related to
adjustment issues and anxiety order care plan with interventions to administer medications as ordered and
to monitor for side effects of the medication.
Review of the medical record for Resident #48 revealed an April 2023 medication administration record
(MAR) which indicated Resident #48 received Lorazepam 1 mg by mouth daily on 04/01/23, 04/02/23,
04/03/23, 04/04/23, 04/05/23, 04/08/23, 04/09/23, 04/10/23, 04/12/23, 04/17/23, 04/18/23, and 04/19/23.
Review of the medical record for Resident #48 revealed it did not contain documentation to support
Resident #48 was offered non-pharmacological interventions prior to the administration of PRN Lorazepam
or physician documentation to support the use of the PRN Lorazepam greater than 14 days.
Interview on 04/20/23 at 8:38 A.M., with the Director of Nursing (DON) confirmed Resident #48's
Lorazepam was ordered as PRN and did not have an end date to the order. The DON confirmed the
medical record did not contain documentation to support the continued use of the PRN Lorazepam. The
DON also confirmed the facility had no evidence of Resident #48 being offered non-pharmacological
interventions prior to administering the PRN antianxiety medication.
Review of the undated policy titled, Psychotropic Gradual Dose Reduction, stated the physicians will
prescribe psychotropic medications appropriately with the interdisciplinary team to ensure the continual
appropriate use, evaluation, and monitoring of medication. Staff are to document rationale/diagnosis for use
and identify target symptoms.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365936
If continuation sheet
Page 8 of 11
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
365936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Retirement Community of Lima Inc
2440 Baton Rouge Avenue
Lima, OH 45805
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 0770
Provide timely, quality laboratory services/tests to meet the needs of residents.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
Findings include:
Review of medical record for Resident #35 revealed admission date of 12/16/20, with diagnoses including
schizoaffective disorder, bipolar type, anxiety, depression, and dementia with behavioral disturbances. The
resident remains in the facility.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely/never
understood with severely impaired cognition. She required extensive one person assistance for bed
mobility, transfers, eating toileting and personal hygiene.
Review of the care plan for actual impairment to skin integrity related to left second toe with drainage and
edema. Interventions included but were not limited to monitor and document size and treatment of skin
injury. Report failure to heal, signs and symptoms of infections to physician.
Review of progress note dated 04/06/23 revealed a wound to Resident #35's left second toe was noted on
04/03/23. The wound nurse assessed the wound which was described as the entire toe was edematous
with the base of the nail lifting upward, scant amount of serous drainage. The social worker was notified of
the need for a podiatry consult.
Review of progress note dated 04/13/23 revealed the wound nurse had been in to assess Resident #35,
her left second toe wound was documented as edematous, with base of nail lifting upward and a large
amount of purulent drainage. The social worker informed facility wound nurse Licensed Practical Nurse
(LPN) #544 of an outside podiatrist needed to be consulted.
Review of the physician orders revealed an order for a C-Reactive Protein (CRP) and wound culture.
Review of the CRP results dated 04/13/23 revealed it was less than 0.1 (within normal limits) milligrams per
liter (mg/L). There were no culture results in the electronic chart.
Interview on 04/20/23 at 7:32 A.M., with the Director of Nursing revealed the wound culture for Resident
#35 was picked up by the lab but was lost. She confirmed it was the responsibility of the facility to follow up
with orders to ensure they were resulted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365936
If continuation sheet
Page 9 of 11
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
365936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Retirement Community of Lima Inc
2440 Baton Rouge Avenue
Lima, OH 45805
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 0825
Provide or get specialized rehabilitative services as required for a resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
Findings included:
Review of the medical record for Resident #203 revealed an admission date of 04/11/23, with medical
diagnoses of acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease
(COPD), malignant neoplasm of retromolar area, and anxiety. Review of the medical record revealed
Resident #203's payer source was Medicaid.
Review of the medical record for Resident #203 revealed a nursing admission assessment, dated 04/11/23,
which stated Resident #203 was alert and oriented to person, place, time, and situation and was dependent
upon staff for bed mobility, transfers, toileting, and extensive assist for dressing and grooming.
Review of the medical record for Resident #203 revealed hospital discharge orders, dated 04/11/23, for
Physical therapy (PT), Occupational therapy (OT), and Speech therapy (ST) to evaluate and treat.
Review of the medical record for Resident #203 revealed an activities of daily living (ADL) self-care deficit
related to COPD, anxiety, severe protein calorie malnutrition and weakness care plan with interventions for
staff to provide assistance with Activities of Daily Living (ADLs) and PT, OT, ST to evaluate and treat per
doctor's orders.
Review of the medical record for Resident #203 revealed a physician order 04/11/23, for PT, OT, and ST to
evaluate Resident #203. Further review of the medical record for Resident #203 revealed an order dated
04/12/23 to discontinue PT and OT evaluations. The medical record revealed a clarification order dated
04/15/23 for ST to provide services three times per week for 30 days due to swallowing dysfunction.
Review of the medical record for Resident #203 revealed a Social Service assessment, dated 04/12/23,
stated Resident #203's discharge goal was to return home with spouse and daughter.
Interview on 04/18/23 at 9:22 A.M., with Resident #203 stated she wanted to get stronger so she could go
home but has not had any therapy services since her admission to the facility on [DATE].
Interview on 04/19/23 at 11:43 A.M., with Physical Therapy Assistant (PTA) #601 stated Resident #203 had
only been evaluated for ST services because the Interdisciplinary Team (IDT) determined her swallowing
issues were the most important medical condition to treat upon admission. PTA #601 stated she believed
the facility policy for residents who require therapy services and have Medicaid as a payer source, was to
only receive one therapy service at a time. PTA #601 stated she believed Resident #203 would benefit from
PT and OT services.
Interview on 04/29/23 at 1:16 P.M., interview with admission Director #571 stated if a Medicaid payer
resident admitted to the facility, the therapy services would conduct PT, OT, or ST evaluations
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365936
If continuation sheet
Page 10 of 11
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
365936
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Retirement Community of Lima Inc
2440 Baton Rouge Avenue
Lima, OH 45805
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 0825
Level of Harm - Minimal harm
or potential for actual harm
as ordered. The admission Director #571 stated if therapy determined the resident required therapy
services, based on the evaluations, the therapy director would email the owner of the facility for
authorization for 10 therapy treatments. The admission Director #571 stated therapy would continue to
email the owner of the facility with updated progress notes for the therapy services to get authorization for
further treatment if needed.
Residents Affected - Few
Interview on 04/29/23 at 1:49 P.M., with PTA #601 confirmed Resident #203 had not be screened or
evaluated by PT or OT services since admission on [DATE].
Interview on 04/19/23 at 1:49 P.M., with Rehab Director (RD) #600 via phone stated all new admissions are
screened for therapy services upon admission. RD #600 stated if a resident had Medicaid as a payer
source, she would email the owner of the facility for authorization to provide treatments. RD #600 stated
she had never been denied, by the owner of the facility, to provide therapy services if there was a medical
need or because of payer source. RD #600 stated due to limited availability of evaluating therapists, there
have been times when residents have not had therapy evaluations completed timely. RD #600 confirmed
Resident #203 was not evaluated by PT and OT services due to the facility did not having an evaluating PT
or OT to complete the evaluations.
Interview on 04/20/23 at 9:34 A.M., with Director of Nursing (DON) #526 confirmed Resident #203 had
orders for PT, OT, and ST evaluations and treatment upon admission and the orders were discontinued on
04/12/23 prior to the evaluations being completed.
This deficiency represents the noncompliance discovered during the complaint investigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365936
If continuation sheet
Page 11 of 11
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Back to topCitations
6 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.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F687 - Foot care
Provide appropriate foot care.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
FAQ · About this visit
Common questions about this visit
What happened during the April 20, 2023 survey of LIBERTY RETIREMENT COMMUNITY OF LIMA INC?
This was a inspection survey of LIBERTY RETIREMENT COMMUNITY OF LIMA INC on April 20, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LIBERTY RETIREMENT COMMUNITY OF LIMA INC on April 20, 2023?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
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.