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Complaint Investigation

Shawnee Manor

February 26, 2026 · Lima, OH · 2535 Fort Amanda Road
Citations 1
CMS Rating 4/5
Beds 137
Provider ID 365361
Healthcare Facility
Shawnee Manor
Lima, OH  ·  View full profile →
Inspection Summary

SHAWNEE MANOR in LIMA, OH — inspection on February 26, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0695
Quality of Life and Care Deficiencies

Positive Airway Pressure (BiPAP)/Continuous Positive Airway Pressure (CPAP) Continuous Positive

plan.

This affected one (Resident #1 )of three residents reviewed for the use of CPAP machines.

The facility census was 129.Findings include:

Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE] and discharged to another facility on 10/14/25.

Diagnoses included congestive heart failure, obstructive sleep apnea, bronchiectasis, and chronic respiratory failure.

The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition and was receiving non-invasive oxygen therapy.The care plan dated 05/18/22 revealed Resident #1 was at risk for altered respiratory status.

Interventions include assist Resident #1 ensuring the BiPAP)/CPAP mask was in place per order nightly.Review of Resident #1's physician orders dated 08/11/22 to 10/14/25, including discharge orders, revealed there was no physician order for the BiPAP/CPAP therapy machine.

Per the order dated 05/04/24 the staff were ordered to cleanse the BiPAP mask weekly every Sunday.Resident #1's medical record including Treatment Administration Records (TAR), task worksheets, and nursing progress notes did not have evidence the BiPAP/CPAP was administered to Resident #1 every night as noted in the care plan.Interview on 02/26/26 at 11:50 A.M. with Resident #1's family representative revealed the resident did have an order upon admission to the facility for a CPAP machine.

Per the family representative, the facility failed to ensure the resident was using the CPAP machine the physician's order.

The family representative stated she was informed the resident was not always using the CPAP machine but was not told when the resident was refusing the therapy.Interview on 02/26/26 at 2:15 P.M. with the Administrator and the Director of Nursing (DON) verified Resident #1's medical records were lacking in documentation regarding the administration of the BiPAP/CPAP machine and verified there were no physician orders to administer it nightly but there should have been.

This deficiency represents non-compliance under Complaint Number 2705837.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LIMA, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SHAWNEE MANOR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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