Skip to main content
Complaint Investigation

Louisville Gardens Care Center

September 4, 2025 · Louisville, OH · 4466 Lynnhaven Avenue Ne
Citations 4
CMS Rating 2/5
Beds 99
Provider ID 366141
Healthcare Facility
Louisville Gardens Care Center
Louisville, OH  ·  View full profile →
Inspection Summary

LOUISVILLE GARDENS CARE CENTER in LOUISVILLE, OH — inspection on September 4, 2025.

Found 4 citations. 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.

Advertisement

Inspection Findings

FF0657
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

Review of Resident #21's medical record revealed an admission date of 04/02/25 with diagnoses including schizoaffective disorder bipolar type, paranoid schizophrenia, anxiety, psychosis, diabetes mellitus type II, asthma, chronic pain, and non-Hodgkin lymphoma.

Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact and required minimal assistance with activities of daily living.

Interview on 09/02/25 at 11:50 A.M. with Resident #21 revealed they did not get invited to care conferences.

Record review revealed a social services progress note for an initial care conference on 04/17/25, with no other care conferences documented.

Interview on 09/04/25 at 10:18 A.M. with SSD #566 confirmed a care conference was not completed for the third quarter of 2025.

Review of the facility policy titled Care Plans, Comprehensive Perso-Centered revealed care plan interventions were chosen after gathering data and careful consideration of the relationship between the resident's problems and their causes and relevant clinical decision making.

Assessments were ongoing and care plans would be revised as conditions changed.

The interdisciplinary team would review and update the care plan when there was a significant change in the resident's condition or at least quarterly in conjunction with their required quarterly MDS assessment.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Louisville Gardens Care Center

4466 Lynnhaven Avenue NE Louisville, OH 44641

SUMMARY STATEMENT OF DEFICIENCIES

Review of the shower schedule revealed Resident #47 was scheduled to receive showers on Sundays and Wednesdays.

Review of the shower sheets for August 2025 revealed Resident #47 revealed she received a shower on 08/24/25 and a bed bath on 08/10/25.

She refused a shower on 08/13/25, 08/17/25, 08/20/25 and 08/27/25.

There was no documented evidence Resident #47 was offered a bed bath or shower on a different day or time after the refusal of the showers.

Interview on 09/02/25 at 10:39 A.M. with Resident #47 revealed she did not get showers because the facility no longer had a shower aide.

Interview on 09/04/25 at 7:50 A.M. with CNA #508 revealed she was often not able to get all showers completed each day.

Interview on 09/04/25 1:44 P.M. with the Administrator confirmed she was aware the facility had not been consistently providing showers to residents.

Review of the facility policy titled Shower/Tub Bath, dated 2001, revealed the facility would document the date and time the shower or bath was performed and the name of the individual assisting the resident with the shower or bath. If the resident refused, the reasons why and the interventions taken would be documented as well.

This deficiency represents noncompliance investigated under Complaint Number 1395034 (OH00167579).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Louisville Gardens Care Center

4466 Lynnhaven Avenue NE Louisville, OH 44641

SUMMARY STATEMENT OF DEFICIENCIES

During the interview, LPN #589 also reported once the medication was ordered, it seemed to take a long time before it was delivered.

Review of the medication bottle at the time of the interview revealed the medication came from Health [NAME] Pharmacy in Lakeland, Florida.

Interview on 09/04/2025 at 1:35 PM with the Director of Nursing (DON) verified the dates the sevelamer was reordered included 07/08/25 and 08/27/25.

During the interview, the DON was unable to confirm the date the medication was received by the facility, stating the medication went directly to the resident, and the facility did not have a process to record receipt of medications from this particular pharmacy.

Review of the prescription reorder information form revealed sevelamer was reordered on 07/08/25 and 08/27/25.

Review of the shipping invoice from Health [NAME] Pharmacy revealed the sevelamer was last shipped to the facility, to the attention of the DON, on 08/27/25.

The facility did not have the shipping invoice for previous sevelamer orders.

Review of the policy titled Medication Orders and Receipt Record, last revised April 2007, revealed the charge nurse was to maintain medication order and receipt records and that medications were to be ordered in advance based on the pharmacy's required lead time.

This deficiency represents noncompliance investigated under Master Complaint Number 2600257 and Complaint Number 1395034 (OH00167579).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Louisville Gardens Care Center

4466 Lynnhaven Avenue NE Louisville, OH 44641

SUMMARY STATEMENT OF DEFICIENCIES

Review of the policy titled Answering the Call Light, last revised March 2021, revealed staff were to provide a timely response to resident's requests and needs.

The policy further revealed that if staff were able to perform the requested task, it should be completed within five minutes of knowledge of what they needed/requested.

This deficient practice represents noncompliance investigated under Complaint Number 1395034 (OH00167579).

Facility ID:

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 LOUISVILLE, 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 LOUISVILLE GARDENS CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

Advertisement