Health inspection·December 6, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents were provided meals according to their preferences. This affected two residents (#20 and #21) of three residents reviewed for meal service. The facility census was 42. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 01/15/24. Diagnoses included cerebral infarction, dysphagia, type II diabetes, gout and convulsions. Review of Resident #20's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #20 was moderately cognitively impaired. Resident #20 displayed no behaviors during the review period. Resident #20 had no weight changes at the time of the review. Review of Resident #20's care plan revised 10/21/24 revealed supports and interventions for self-care deficit, limited physical mobility, resistant to care, potential for verbal aggression, impaired cognitive function, seizures, and potential for nutritional problem. Supports and interventions for nutrition included monitor intakes, weights as ordered, and provide diet as ordered. Review of Resident #20's dietary order dated 07/15/24 revealed Resident #20 was to receive a regular diet, regular texture and thin consistency liquids. Resident #20 was to receive a liberal amount of sauces/gravies to moisten meal. Review of Resident #20's Meal Tickets dated 12/06/24 revealed for breakfast Resident #20 Allergies/Dislikes included no eggs, no French toast, and no oatmeal. Her lunch Allergies/Dislikes included no bologna, no eggs, and no French toast and her Dinner Allergies/Dislikes included no bologna, no eggs, and no French toast. Observation on 12/06/24 at 8:09 A.M. of Resident #20 found her being provided her breakfast tray by Certified Nursing Assistant (CNA) #110. Resident #20 stated she was unhappy with her meal as there were scrambled eggs on her plate and she had told them over and over again she did not want eggs. Interview on 12/06/24 at 8:12 A.M. with Resident #20 found her to be alert and aware. Resident #20 stated her food was warm, but she was not provided what she wanted. Resident #20 reported she did not eat any eggs and it was a waste of time and food because the kitchen kept giving her eggs. Resident #20 stated she was not sure why because it was on her ticket she did not want eggs. Coinciding (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 2 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 12/06/2024 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)