St Luke Lutheran Community-Portage Lakes
615 Latham Ln, Akron, OH 44319 · Non profit - Corporation · 56 certified beds · (330) 644-3914 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (81%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.1% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 7.1% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.7% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 57.8% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.2% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 4.9% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 27.4% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.6% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.9% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.0% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 7.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 75.0% | 75.6% | 79.4% | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 56 beds and averages 47.0 residents a day — about 84% occupied, or roughly 9 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.05 hrs/resident/day on weekends vs 3.19 on weekdays — 4% thinner on weekends. RN hours go from 0.21 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 81% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2024-09-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, review of facility policy, and review of a facility self-reported incident (SRI) investigation, the facility failed to ensure Resident #7 was free from staff to resident physical abuse. This affected one resident (#7) of three residents reviewed for abuse. The facility census was 38. Actual harm occurred on 09/09/24 when Resident #7 was physically abused by a State Tested Nursing Assistant (STNA) during care resulting in large areas of bruising to both of the resident's arms. Bruising to the left upper arm measured 4.5 centimeters (cm) in length by 3.0 cm width and was described as purple to dark red in color. Bruising to the right upper arm measured 15.0 cm in length by 6.0 cm with and was described as deep purple and dark red with intact skin. A facility SRI dated 09/09/24 indicated Resident #7 reported pain as a result of in incident, however the type or level of pain was not described. An interview with Resident #7 by the Director of Nursing (DON) on 09/09/24 about…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed develop a comprehensive care plan for wounds and wound care for Resident #1. This affected one resident (Resident #1) out of three residents reviewed for wound care. The facility census was 40. Findings include: Review of Resident #1's medical record revealed an admission date of 12/05/16. Diagnoses included dementia, cerebral infarction, ataxia, diabetes mellitus, anxiety disorder, seizures, drug induced subacute dyskinesia, muscle wasting and atrophy. Review of Resident #1's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #1 required supervision or touching assistance for eating, substantial to maximal assistance for bed mobility, and was dependent on staff for oral hygiene, toileting, showers, dressing, and personal hygiene. Review of the facility document titled Provider Consultation, dated 12/05/24 and authored by WCNP #807 revealed the WCNP #807 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure wound care treatments were completed timely and per physician orders for Resident #41. This affected one resident (Resident #41) out of three residents reviewed for wound care. The faciltiy census was 40. Findings include: Review of Resident #41's medical record revealed an admission date of 12/13/24 and a discharge date of 12/21/24. Diagnosis included cellulitis of right lower extremity, sepsis, fracture of right tibia, type two diabetes, atrial fibrillation, rash, head laceration, wedge compression fracture of T4, ulcerative colitis, age related osteoporosis, nicotine dependency, and gastroesophageal reflux disease. Review of Resident #41's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 had intact cognition. They required supervision or touching assistance for eating, set up or clean up assistance for bed mobility, and partial to moderate assistance for oral hygiene, toileting, showers, dressing and personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-29 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the residents medical record was complete and reflected treatment orders put in place for wound care. This affected one resident (Resident #1) of three residents reviewed for wound care. The facility census was 40. Findings Include: Review of Resident #1's medical record revealed an admission date of 12/05/16. Diagnoses included dementia, cerebral infarction, ataxia, diabetes mellitus, anxiety disorder, seizures, drug induced subacute dyskinesia, muscle wasting and atrophy. Review of Resident #1's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #1 required supervision or touching assistance for eating, substantial to maximal assistance for bed mobility, and was dependent on staff for oral hygiene, toileting, showers, dressing, and personal hygiene. Review of the facility document titled Provider Consultation, dated 12/05/24 and authored by WCNP #807 revealed the WCNP #807…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-27 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interview, the facility failed to provide the correct Quality Improvement Organization (QIO) information to residents who were completing therapy. This affected three (Resident #145, Resident #146 and Resident #147) of three reviewed for liability notices. The census was 37. Findings include: 1. Review of Resident #145's medical record revealed they were readmitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 09/26/24. The letter did not provide the correct QIO information. Interview on 11/27/24 at 11:45 A.M. with the Administrator and Social Service Designee #240 verified the letters to the residents did not provide the correct QIO information. 2. Review of Resident #146's medical record revealed they were admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 08/31/24. The letter did not provide the correct QIO information.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, review of shower documentation and interviews the facility failed to ensure residents received adqueate assistance with activities of daily living to completed showers as scheduled. This affected three residents (Resident #15, Resident #25 and Resident #29) of three residents reviewed for showers. The census was 37. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 07/22/22. Diagnoses included complete lesion at T-7 through T-10 level of thoracic spinal cord, neuromuscular dysfunction of bladder and hypotension. The resident was cognitively intact. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was dependent for showers. Review of the shower sheets for the last 60 days revealed showers were offered or given on 09/09/24, 09/11/24, 11/07/24 and 11/25/24. Interview on 11/25/24 at 10:06 A.M. with Resident #15 revealed he did not getting showers as scheduled. Interview on 11/26/24 at 6:30 P.M. with the Director…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-27 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure Resident #29 received meals as scheduled to meet their dietary needs. This affected one resident (Resident #29) of three residents reviewed for meal service. Findings include: Review of the medical record for Resident #29 revealed an admission date of 11/01/24. Diagnoses included radiculopathy of lumbar region, type 2 diabetes mellitus and hyperlipidemia. He was on a regular diet with thin liquids. Review of the 5-day Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Interview on 11/25/24 at 11:37 A.M. with Resident #29 revealed he was not served breakfast one day and lunch another day but couldn't recall the dates. Interview on 11/26/24 at 4:00 P.M. with the Food Service Director #213 revealed she was off the day Resident #29 was admitted and therefore there was no diet card created for him. She stated she believed he missed at least two meals from the kitchen. Interview on 11/26/24 at 6:30 P.M. with the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-30 · tag F0919 — failed to provide a working call system — widespreadMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of call light audits, and review of facility policy, the facility failed to maintain a resident call system that adequately communicated resident calls directly to a staff member or to a centralized location to alert staff to a resident in need. This had the potential to affect all residents in the facility. The facility census was 38. Findings include: Observation of the call lights from the centralized common area (between all four halls) on 09/24/24 from 9:36 A.M. to 10:00 A.M. revealed the following: • room [ROOM NUMBER]: At 9:36 A.M. the call light was on. It was not observed what time room [ROOM NUMBER]'s light was triggered. This light was answered at 9:46 A.M. for a total of 10 minutes. • room [ROOM NUMBER]: At 9:38 A.M., room [ROOM NUMBER]'s light was noted to be lit above the room door. Staff responded to the call light at 9:55 A.M. for a total of 17 minutes observed. • room [ROOM NUMBER]: At 9:38 A.M. the light at the end of the North hallway was on, indicating…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-30 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, review of facility policy, and review of facility self-reported incident (SRI) investigation, the facility failed to ensure allegations of potential abuse were thoroughly investigated, thereby preventing further similar instances of abuse involving the same resident. This affected one resident (Resident #7) of three residents reviewed for abuse. The facility census was 38. Findings include: Review of the medical record for Resident #7 revealed an admission date of 07/27/24 with diagnoses including hypertensive heart disease without heart failure, asthma with status asthmaticus, dementia with agitation, depression, type two diabetes mellitus, pulmonary fibrosis, left eye cataract, dizziness, and insomnia. Review if the admission Minimum Data Set (MDS) 3.0 assessment completed on 08/02/24 revealed Resident #7 had intact cognition. Resident #7 was always continent of urine but required substantial assistance for toileting hygiene, bathing, personal hygiene, chair to bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, interview, and review of facility policy, the facility failed to review and revise the comprehensive care plan as resident needs and required interventions changed. This affected one resident (Resident #10) of three residents whose care plans were reviewed for timely and appropriate interventions. The facility census was 38. Findings include: Review of the medical record for Resident #10 revealed an admission date of 02/29/24 with diagnoses including senile degeneration of the brain, dysphagia, hemiplegia or hemiparesis of the left dominant side following a cerebrovascular accident, major depressive disorder, anxiety disorder, and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 09/03/24 revealed Resident #10 had severely impaired cognition, impaired range of motion on one side and was dependent for eating. The MDS also revealed Resident #10 was not on any mechanically altered or therapeutic diet. Review of the physician orders revealed the following meal related orders: • An order dated 02/29/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-05 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to accommodate Resident #13's preference in regard to transferring out of bed. This affected one (Resident #13) of three residents revealed for mechanical lift transfers. Findings include: Review of the medical record for Resident #13 revealed an admission date of 09/26/23 with diagnoses of cerebral infarction, hemiplegia affecting left non-dominant side, alcoholic fatty liver, morbid obesity, diabetes, restlessness and agitation, and depression. Review of the of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #13 was moderately cognitively impaired, required substantial/maximal assistance with rolling left and right in bed, was totally dependent on staff for transferring from the bed to the chair and used a wheelchair for mobility. Review of the self-care deficit care plan updated 09/26/23 revealed Resident #13 had a self-care deficit related to status post cerebral vascular accident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · E2023-10-25 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview and policy review the facility failed to ensure narcotic medication were reconciled each shift for medication carts two and three. This affected 10 residents (Resident #3, #5, #8, #23, #24, #25, #29, #30, #31, #33) who received narcotic medication from medication cart two and three. The facility census was 31. Findings included: Review of the narcotic reconciliation sheet for medication cart two revealed no documentation the shift to shift narcotic reconciliation was completed on 10/11/23, 10/16/23, 10/17/23 and 10/18/23. Review of the narcotic reconciliation sheet for medication cart three revealed no documentation of the shift-to-shift narcotic reconciliation was completed on 10/13/23, 10/17/23 and 10/18/23. On 10/18/23 at 9:20 A.M. an interview with Registered Nurse #100 revealed she had completed the narcotic count with the night shift nurse but the night shift nurse was in a hurry and never documented narcotic reconciliation had occurred. On 10/19/23 at 9:00 A.M. an interview with the Director of Nursing verified the narcotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interview and facility policy review, the facility failed to ensure physician orders and comprehensive assessments were completed prior to the implementation of physical restraints. This affected two residents (Resident #2 and #9) of three residents reviewed for restraints. The census was 31. Findings included: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, cerebral infarction, diabetes, anxiety disorder, vascular dementia, seizures, drug induced dyskinesia, impulse disorder, insomnia, abnormal posture, and lack of coordination. Review of the plan of care dated 01/23/23 revealed Resident #2 was at risk for falls due to balance issues, antidepressant medication use, no recent falls, was transferred with a Hoyer (brand of mechanical sling lift). Interventions included self-releasing seatbelt in the wheelchair. Review of the Modification to the quarterly Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, manufacturer guideline review, policy review and interview the facility failed to ensure comprehensive wound management was provided per orders and care plan. This affected one resident (Resident #18) of three residents reviewed for pressure ulcers. The census was 31. Findings included: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included abnormal posture, severe protein-calorie malnutrition, cerebral palsy, and epilepsy. The resident was discharged to the hospital on [DATE] and re-admitted to the facility on [DATE]. Review of the Discharge Minimum Data Set assessment dated [DATE] revealed Resident #18 had moderately impaired cognition and no unhealed pressure injures. Review of the nurse's note dated 09/24/23 at 12:18 A.M. revealed Resident #18 had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white substance in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, facility policy review and product safety data sheet review the facility failed to ensure hazardous chemicals were properly stored and failed to ensure fall interventions were in place for Resident #2. This had the potential to affect five residents (Resident #2, #6, #14, #15, and #24) identified with impaired cognition and independent mobility and one resident (Resident #2) of three residents reviewed for falls. The facility census was 31. Findings included: 1. Observation on 10/18/23 at 11:45 A.M. revealed a bottle of toilet bowl cleaner was located on the floor, outside of room [ROOM NUMBER]. No staff were observed. On 10/18/23 at 11:58 A.M. an interview with Registered Nurse #100 verified the toilet bowl cleaner should not be in the hallway unattended. The facility identified Resident #2, #6, #14, #15, and #24 with impaired cognition and independent with mobility. Review of the undated facility policy titled, Environmental Services Safety Procedures, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interview and policy review the facility failed to provide timely incontinence care. This affected one resident ( Resident #2) of three residents reviewed for incontinence. The census was 31. Findings included: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, cerebral infarction, diabetes, anxiety disorder, vascular dementia, seizures, drug induced dyskinesia (uncontrolled movements), impulse disorder, insomnia, abnormal posture, and lack of coordination. Review of the plan of care dated 01/23/23 revealed Resident #2 needed assistance due to incontinence noted and multiple medical conditions. Staff to help with proper change and assist with clothing adjustments. Interventions included check for wetness before meals, after meals, at bedtime and on rounds during the night. Review of the Modification to the quarterly Minimum Data Set assessment dated [DATE] revealed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure oxygen tubing was changed per physician orders. This affected three residents (Resident #3, #6 and #11) of five residents who receive oxygen therapy. The census was 31. Findings included: 1. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, metabolic encephalopathy, acute cough, adult failure to thrive, and heart failure. Review of the physician's orders revealed Resident #3 had an order to change oxygen tubing and nebulizer tubing and date every Sunday night dated 07/24/22. Review of the October Medication administration records revealed no documentation of the oxygen tubing being changed on 10/22/23 for Resident #3. Observation on 10/23/23 at 9:32 A.M. with Agency Registered Nurse #103 revealed the oxygen tubing for Resident #3 was dated 10/16/23. She verified it had not been changed the night before. 2. Review of the medical record revealed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-06-27 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 30 residents currently residing in the facility. Findings include: On 06/22/22 from 10:30 A.M. to 11:30 A.M., facility staffing tool was completed with Scheduler #900. Scheduler #900 stated that four different agencies were utilized to staff the facility. Review of all timecards for facility staff and agency staff for 05/26/22 through 06/01/22, revealed that on 05/26/22 the Interim Director of Nursing (IDON) worked in the facility 3.75 hours. Scheduler #900 verified the IDON was agency contracted and confirmed the timecard at the time of the finding. Further review of agency timecards for 05/26/22 through 06/01/22, revealed Registered Nurse (RN) #902 worked in the facility on 05/30/22 for 7.0 hours. This was verified by Scheduler #900 at the time of the finding. Phone interview on 06/24/22 at 5:17 P.M. with the Administrator revealed an email was sent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-06-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and facility policy, the facility failed to ensure kitchen food storage and handling was maintained in a safe and sanitary manner. This had the potential to affect 29 of 30 residents receiving food from the kitchen. Resident #12 received no food from the kitchen. The facility census was 30. Findings include: A kitchen tour was conducted on 06/21/22 between 8:25 A.M. and 9:20 A.M. with the Dietary Chef Manager (DCM) #831. Observation of the following packaged foods stored in the kitchen refrigerator were noted to be expired, without a dated label and/or open to the air: mozzarella cheese, American cheese, two jars of beef base, pickle relish, and a head of lettuce. DCM #831 verified the packaged foods listed above was not labeled and/or left open to the air at the time of observation. Observation of the kitchen freezer on 06/21/22 at 8:40 A.M. with DCM #831, revealed the following packaged foods were noted to be expired, without a dated label and/or open to the air: two packages of chicken fingers, blueberry muffins, cranberry muffins, green…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, and interviews the facility failed to implement physician order for a splint to be placed on Resident #12's left hand every night. This affected one (Resident #12) out of one resident for contractures. The facility census was 30. Findings include: Record review revealed Resident #12 was admitted on [DATE] and a readmission date of 12/08/09 with diagnoses including intellectual disabilities, aphasia, contracture, and abnormal posture. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was rarely understood and required extensive assistance of two staff for mobility, toileting, and transfer. Review of the physician's orders for June 2022 revealed the use of left-hand splint (1/2-inch roll) to be worn at bedtime overnight until the A.M. care every day. Observation on 06/22/22 at 6:59 A.M. revealed Resident #12 was lying in bed with no splint to the left hand. Licensed Practical Nurse (LPN) # 814 verified the observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-27 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the pharmacy recommendations were addressed by the physician in a timely manner. This affected two residents (Resident's #4 and #13) of five residents reviewed for unnecessary medications. The facility census was 30. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 12/27/19 with diagnoses including dementia with behavioral disturbances, major depressive disorder, and COVID-19. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had impaired cognition and required extensive assistance for activities of daily living. Resident #4 received antidepressant medication daily over the seven-day look back period. Review of the pharmacy recommendation dated 03/01/22 revealed Pharmacist #827 recommended options to reduce antiplatelet medication. Resident #4 was currently on 81 milligrams (mg) aspirin once a day and clopidogrel (blood thinner) 75 mg given daily in the A.M.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-08-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the facility failed to prepare and serve food in a sanitary manner. This affected 44 of 45 residents residing in the facility (Resident #20 does not take nutrition by mouth). The census was 45. Findings Include: Observations on 07/29/19 at 8:54 A.M., revealed a hood range above the stove and lights covered with a layer of dust and grease. These observations were verified by the Director of Dietary (DD). The DD stated the hood had not been cleaned since 05/22/19; this was verified by a sticker located on the outside of hood range. Observations on 07/30/19 at 11:15 A.M., revealed Kitchen Aide (KA) #302 was observed to be wearing gloves as he grabbed cups, trays and cooked hamburgers on the stove. KA#302 pulled bread out of the bag and placed cold cuts on bread without washing hands or changing gloves. DD verified these observations and instructed KA#302 on proper hand washing and changing gloves. Observations made on 07/30/19 at 4:50 P.M., KA #301 placed a stack of frozen hamburgers on the counter, which had meal trays lying on it.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-08-01 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview the facility failed to ensure medications were secured in the medication cart to prevent them from falling to the floor. This had the potential to affect 19 residents identified as cognitively impaired and independently mobile by the facility (Residents #2, #11, #13, #19, #24, #26, #28, # 29, #30, #31, #32, #33, #35, #36, #38, #39, #40, #44 and #145). The facility census was 45. Findings include: On 07/31/19 between 11:21 A.M. and 11:32 A.M. the surveyor observed the interior of the medication carts with licensed practical nurse (LPN) #400. The Hall Two medication cart had five unidentified loose pills in the bottom of the drawer. There were small holes in the bottom of the drawer which would allow loose pills to fall through and onto the floor. The Hall Three medication cart had five unidentified loose pills in the bottom of the drawer. There were small holes in the bottom of the drawer which would allow loose pills to fall through and onto the floor. This observation was verified with the Registered Nurse (RN) Coordinator on 07/31/19 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-08-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to maintain complete resident care plans. This affected three (Residents #27, #34, and #40) of 18 residents reviewed for complete plans of care. The census was 45. Findings Include: 1. Review of medical record for Resident #27 revealed a diagnosis of unspecified psychosis dated 07/11/19. Review of physician orders revealed the resident is receiving Risperdal (antipsychotic) dated 03/09/19, and Depakote (antiseizure) dated 01/12/19, used for certain psychiatric disorders. Review of plan of care dated 01/25/19 revealed no plan of care or interventions for psychosis or seizures. 2. Review of medical record for Resident #34 revealed diagnoses including acute respiratory failure, cerebral infarction, unspecified, chronic kidney disease, and deep tissue wounds to right foot. Review of physician orders revealed the resident is receiving acetaminophen 500 milligrams dated 06/15/16, morphine 20 milligrams, and tramadol 50 milligrams for pain. Review of plan of care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ST. LUKE LUTHERAN COMMUNITY - PORTAGE LAKES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/30/2004 |
| MOHLER, JOYCE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 07/02/2018 |
| SCHNELL, JAMES | Individual | W-2 MANAGING EMPLOYEE | — | since 06/01/2021 |
| GEHM, JUANITA | Individual | CORPORATE DIRECTOR | — | since 01/01/2005 |
| HANSEN, JEAN | Individual | CORPORATE DIRECTOR | — | since 01/01/2013 |
| KYLE, RONALD | Individual | CORPORATE DIRECTOR | — | since 03/19/2004 |
| TAUSCHER, ROBERT | Individual | CORPORATE DIRECTOR | — | since 01/01/2014 |
| SPIELER, JOHN | Individual | CORPORATE OFFICER | — | since 01/01/2007 |
CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366280. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.