Louisville Gardens Care Center

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

1. 5. 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 REDACTED] 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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Louisville Gardens Care Center

4466 Lynnhaven Avenue NE Louisville, OH 44641

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 0677

intact. She was totally dependent on staff for all ADL.

Level of Harm - Minimal harm or potential for actual harm

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

Residents Affected - Some

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).

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Louisville Gardens Care Center

4466 Lynnhaven Avenue NE Louisville, OH 44641

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 0684

09/02/25 at 5:25 A.M. revealed the medication was not available

Level of Harm - Minimal harm or potential for actual harm

Interview with Resident #1 on 09/02/2025 at 9:02 A.M. revealed he had not been getting his phosphorus binder, the sevelamer, for at least a week or more. The dialysis physician had told him it was taken care of, and nobody was able to explain why he still did not have the medication.

Residents Affected - Few

Interview on 09/04/2025 at 10:12 A.M. with Resident #1 confirmed he received the sevelamer the last two days, but there were gaps when he did not receive the medication for several days at a time. Resident #1 further revealed when not taking the medication, he felt nauseous and would often experience diarrhea, with more prominent symptoms after meals.

Interview on 09/04/2025 at 10:16 AM with Licensed Practical Nurse (LPN) #589 confirmed she thought the pharmacy had not been sending the sevelamer, but then another nurse had told her it had to be special ordered. 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).

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Louisville Gardens Care Center

4466 Lynnhaven Avenue NE Louisville, OH 44641

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

be left unattended and had to get a nurse from another unit to come help with Resident #23's care. During

the interview, CNA #567 reported that the aide that was scheduled at 3:00 P.M. on 09/01/25 and on 09/02/25 did not show up and had been a no-call, no-show several times. CNA #567 further reported informing the scheduler there was no aide to relieve her and later received a text message thanking her for staying and then telling CNA #567 that she was good to go home. CNA #567 confirmed leaving the facility with only one nurse working on the 400 unit and no aide on the afternoon shift of 09/02/25.

Interview on 09/03/25 5:10 P.M. interview with Resident #1 confirmed he had placed his call light on just

before dinner on 09/02/25, and it remained unanswered for greater than 30 minutes. By the time someone came in the room with his dinner tray, he had forgotten why he activated the light on in the first place (during the interview, Resident #1 recalled he had some bleeding from his backside he thought he should report to someone).

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).

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet