Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Luke Lutheran Community-portage Lakes during CMS and state inspections, most recent first.
A facility failed to develop a comprehensive care plan for a resident with a new coccyx wound. Despite a WCNP ordering specific treatments, no care plan was created. The resident had multiple diagnoses, including dementia and diabetes, and required significant assistance. The deficiency was confirmed by the DON and ADON, who acknowledged the oversight, which was against the facility's policy for baseline care plans.
A facility failed to provide timely and proper wound care for a resident with a complex medical history, including venous stasis ulcers. The resident's care plan required specific interventions, but treatments were not completed on multiple occasions. An LPN responsible for the missed treatments was terminated for insubordination after failing to perform the required care, as confirmed by the DON and ADON.
A facility failed to ensure a resident's medical record accurately reflected wound care treatment orders. Despite the nursing staff following the WCNP's orders, these were not transcribed into the EMR or TAR. Interviews confirmed the orders were never entered, highlighting a lapse in maintaining accurate medical records.
The facility failed to provide the correct QIO information in the NOMNC letters to three residents completing therapy. The deficiency was confirmed through interviews with the Administrator and Social Service Designee, revealing that the letters lacked accurate QIO details.
The facility failed to ensure that three residents, who were dependent on staff for showering, received showers as scheduled. Despite being cognitively intact or impaired, these residents did not receive the necessary assistance with activities of daily living, as confirmed by interviews and shower documentation. The Director of Nursing verified the lack of evidence for scheduled showers.
A resident with type 2 diabetes and other conditions did not receive scheduled meals due to the absence of a diet card, as confirmed by the Food Service Director and DON. The resident missed at least two meals, and a concern was logged when a dinner tray was not served timely, leading to food being sourced externally.
A resident in an LTC facility suffered significant bruising on both arms due to rough handling by an STNA. Despite reports of similar past incidents, the facility's investigation was inadequate, failing to substantiate abuse or prevent further harm. The facility's policy on preventing resident harm was not effectively followed, leading to non-compliance.
The facility's call system failed to alert staff effectively, leading to delayed responses to residents' needs. Observations showed call lights were not promptly answered, and interviews revealed residents' concerns about long wait times. Staff confirmed the lack of a functioning pager system, relying on visual checks of hallway lights. Call light response audits showed significant delays, indicating a systemic issue.
A resident with dementia and other medical conditions sustained bruises on both arms due to alleged rough handling by staff during night shifts. The facility's investigation was inadequate, lacking direct witness testimony and proper documentation. Interviews revealed inconsistencies and poor communication, leading to the placement of two agency staff on a do-not-return list.
A facility failed to update a resident's care plan to reflect changes in meal assistance needs and dietary orders. Despite physician orders for meal assistance and a regular diet, the care plan lacked necessary interventions. Staff interviews revealed inconsistencies in meal assistance and documentation, with some unaware of the need to log meal intake. The DON confirmed the care plan did not accurately reflect the resident's current needs, and there was no record of interdisciplinary meetings to address these issues.
A resident with significant medical needs was not assisted out of bed according to their preference, despite requesting to be transferred after breakfast. The staff delayed the transfer, prioritizing other tasks, which led to the resident remaining in bed for an extended period. The facility's policy on transferring non-ambulatory residents was not followed, and the deficiency was acknowledged by the DON and interim Administrator.
Failure to Develop Comprehensive Wound Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a new wound on the coccyx. The resident, who had multiple diagnoses including dementia, cerebral infarction, and diabetes mellitus, was admitted with severely impaired cognition and required substantial assistance with daily activities. Despite a consultation with a Wound Care Nurse Practitioner (WCNP) who ordered specific treatments for the wound, the facility did not create a care plan to address the wound care needs. The deficiency was confirmed during an interview with the Director of Nursing and the Assistant Director of Nursing, who acknowledged that a wound care plan had not been developed for the resident. The facility's policy on baseline care plans, which mandates the development of a care plan for each resident to provide effective and person-centered care, was not followed. This oversight was identified during the investigation of a complaint, highlighting a lapse in adhering to professional standards of quality care.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to ensure timely and proper wound care treatments for a resident, identified as Resident #41, as per physician orders. Resident #41 had a complex medical history, including cellulitis, sepsis, diabetes, and venous stasis ulcers, which required specific wound care interventions. The care plan for Resident #41 included various interventions to prevent skin breakdown, such as the use of barrier creams, pressure reduction mattresses, and regular repositioning. However, the Treatment Administration Record (TAR) indicated that the prescribed treatments were not completed on several occasions, specifically on 12/17/24, 12/18/24, and 12/21/24. Interviews with facility staff revealed that LPN #805 was responsible for the missed treatments and had been previously educated and disciplined for similar issues. Despite these measures, LPN #805 failed to perform the required treatments, leading to their termination on 12/22/24 for insubordination. The Director of Nursing and the Assistant Director of Nursing confirmed the non-compliance with the treatment orders, which was a significant factor in the deficiency identified during the investigation of Complaint Number OH00160998.
Incomplete Medical Record for Wound Care
Penalty
Summary
The facility failed to ensure that Resident #1's medical record was complete and accurately reflected the treatment orders for wound care. Resident #1, who had multiple diagnoses including dementia and diabetes mellitus, was admitted with a new wound to the coccyx. The wound care nurse practitioner (WCNP) ordered specific treatments for the wound, which were not transcribed into the Electronic Medical Record (EMR) physician orders. Despite the nursing staff following the treatment orders as noted in progress notes, the orders were absent from the official physician orders and the Treatment Administration Record (TAR). Interviews with the Licensed Practical Nurse (LPN), Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed that the orders were never entered into the EMR. The WCNP stated that it was the facility's responsibility to ensure her orders were entered into the EMR. The deficiency was identified during an investigation of a complaint, highlighting a lapse in the facility's process for maintaining accurate and complete medical records for wound care management.
Incorrect QIO Information in NOMNC Letters
Penalty
Summary
The facility failed to provide the correct Quality Improvement Organization (QIO) information in the Notice of Medicare Non-Coverage (NOMNC) letters to residents who were completing therapy. This deficiency affected three residents, as identified in the report. Resident #145 was readmitted to the facility, and their services ended on 09/26/24, but the NOMNC letter did not include the correct QIO information. Similarly, Resident #146, admitted to the facility, had their services ended on 08/31/24, and Resident #147, also admitted, had their services ended on 02/20/24, both without the correct QIO information in their NOMNC letters. Interviews conducted on 11/27/24 with the Administrator and Social Service Designee #240 confirmed that the letters provided to these residents did not contain the correct QIO information. This oversight in providing accurate information in the NOMNC letters was identified during the review of the residents' medical records and staff interviews.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically in ensuring that residents received showers as scheduled. This deficiency affected three residents who were dependent on staff for showering. Resident #15, who has a complete lesion at the T-7 through T-10 level of the thoracic spinal cord and is cognitively intact, did not receive showers twice a week as scheduled. The shower documentation for Resident #15 showed that showers were only offered or given on four occasions over a 60-day period, which was confirmed by both the resident and the Director of Nursing. Similarly, Resident #25, who has Down Syndrome, difficulty walking, and anxiety disorder, and is cognitively impaired, also did not receive showers twice a week as scheduled. The shower records indicated sporadic showering dates, which were insufficient according to the schedule. Resident #29, with diagnoses including radiculopathy of the lumbar region and type 2 diabetes mellitus, also did not receive showers as scheduled, with records showing only one shower since admission. Interviews with the residents and the Director of Nursing confirmed the lack of adherence to the scheduled showering routine for these residents.
Failure to Provide Scheduled Meals to Resident
Penalty
Summary
The facility failed to ensure that Resident #29 received meals as scheduled to meet their dietary needs. Resident #29, who was admitted with diagnoses including radiculopathy of the lumbar region, type 2 diabetes mellitus, and hyperlipidemia, was on a regular diet with thin liquids and was cognitively intact. The resident reported not being served breakfast on one day and lunch on another, although he could not recall the specific dates. The Food Service Director confirmed that no diet card was created for the resident due to her absence on the day of admission, resulting in the resident missing at least two meals. The Director of Nursing also confirmed that the resident missed breakfast and dinner, though the dates were unspecified. A concern log noted that the resident had an issue on November 4, 2024, regarding a dinner tray not being served timely, which was resolved by obtaining food from an outside source.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a State Tested Nursing Assistant (STNA), resulting in significant bruising on both arms. The incident occurred when the resident was reportedly handled roughly during care, leading to large bruises on the upper arms. The resident, who had a history of dementia with agitation and other medical conditions, reported pain and described the STNA as being rough. Interviews with the resident and his family revealed that this was not the first instance of bruising from rough handling by staff. The facility's investigation into the incident was inadequate. Although the Director of Nursing (DON) and other staff were aware of the bruising and the resident's report of rough handling, the investigation did not substantiate abuse due to conflicting witness statements and lack of direct observation of the incident. The facility's self-reported incident (SRI) and subsequent interviews with staff and hospice nurses indicated that the resident had experienced similar bruising in the past, which was also reported to the previous DON. Despite these reports, the facility did not conduct a thorough investigation into the previous incident, and the current investigation was inconclusive. The facility's policy on abuse, neglect, and exploitation requires steps to prevent resident harm, including injury from rough handling. However, the facility did not adequately follow this policy, as evidenced by the lack of a comprehensive investigation and failure to prevent further incidents of rough handling. The report highlights the facility's non-compliance with its own policies and the need for more effective measures to protect residents from abuse.
Deficient Call System Response in LTC Facility
Penalty
Summary
The facility failed to maintain an effective resident call system, which compromised the ability to promptly respond to residents' needs. Observations revealed that call lights were activated in several rooms, but staff response times were delayed, ranging from 10 to 17 minutes during a specific observation period. Additionally, there was no audible alert system or centralized panel at the nurses' station to notify staff of activated call lights, and the pagers intended for this purpose were not in use due to missing batteries. Interviews with residents and staff highlighted concerns about the call light response times. Residents expressed frustration with the delays, with one resident reporting a wait time of up to four hours over a weekend. Staff interviews confirmed the lack of a functioning pager system, with STNAs relying solely on visual checks of hallway lights to identify activated call lights. The Director of Nursing acknowledged the expectation for staff to respond immediately or as soon as possible, but the absence of a working notification system hindered this process. A review of call light response audits further demonstrated significant delays, with multiple instances of response times exceeding 20 minutes. The facility's policy required call lights to alert staff directly or through a centralized system, but this was not effectively implemented. The deficiency was investigated under Complaint Number OH00157294, indicating a systemic issue affecting the entire facility's resident population.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of potential abuse, which affected a resident who had been admitted with multiple medical conditions, including dementia with agitation and depression. The resident, who had intact cognition, was noted to have sustained bruises on both arms on two separate occasions. The first incident was reported by a hospice nurse, and the second incident was reported by another hospice nurse, both indicating rough handling by staff during night shifts. The facility's investigation into the incidents was inadequate. The initial report to the Ohio Department of Health did not include corroboration from the resident's power of attorney regarding the separate occurrences. The investigation findings for the second incident did not substantiate abuse due to a lack of direct witness testimony, as the nurse on duty was not present during the alleged rough handling. Additionally, there was no documentation of interviews with witnesses or the alleged perpetrator, and the facility's policy on abuse and neglect was not followed thoroughly. Interviews with the resident, family members, hospice staff, and facility staff revealed inconsistencies and a lack of communication regarding the incidents. The facility's Director of Nursing placed two agency staff members on a do-not-return list due to dishonesty and uncertainty about who provided care during the incidents. The facility administrator was unaware of the actions taken and acknowledged the need for further investigation after new information was brought to light.
Failure to Update Resident Care Plan for Meal Assistance
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident as their needs and required interventions changed. This deficiency affected a resident with multiple diagnoses, including senile degeneration of the brain, dysphagia, hemiplegia, major depressive disorder, anxiety disorder, and neuromuscular dysfunction. The resident had severely impaired cognition and was dependent on assistance for eating, yet the care plan did not reflect the necessary interventions for meal assistance or dietary changes. The resident's care plan, initiated in early March, did not include interventions related to the level of assistance needed for eating, despite physician orders indicating the need for meal assistance and a regular diet with thin liquids. The care plan also failed to document the resident's history of meal refusals, preferences, or the requirement to log meal intake in an orange folder. Interviews with staff revealed inconsistencies in meal assistance and documentation, with some staff unaware of the need to log meal intake or the level of assistance required. The Director of Nursing (DON) confirmed that interdisciplinary team meetings were held quarterly and with changes in condition, but there was no record of these meetings or updates to the care plan. The DON acknowledged that the care plan did not accurately reflect the resident's current diet orders, assistance needs, or history of meal refusals. The facility's policy required comprehensive care plans to be developed and implemented based on assessments of each resident's needs, but this was not adhered to in this case.
Failure to Honor Resident's Transfer Preferences
Penalty
Summary
The facility failed to accommodate a resident's preference regarding their transfer out of bed, which was a violation of the resident's right to self-determination. The resident, who had a history of cerebral infarction, hemiplegia, and other medical conditions, required substantial assistance for mobility and used a mechanical lift for transfers. Despite the resident's request to be transferred out of bed in the morning after breakfast, the staff did not comply with this preference. Observations revealed that the resident remained in bed well into the morning and early afternoon, despite expressing a desire to get out of bed. Interviews with staff confirmed that the resident's request was not prioritized, as the staff member responsible for the resident's care delayed the transfer until after completing other tasks. The resident expressed dissatisfaction with this delay, indicating a lack of respect for their preferences. The facility's AM Care policy, which required non-ambulatory residents to be transferred to a wheelchair, was not followed in this instance. The Director of Nursing and interim Administrator acknowledged that the resident should have been assisted out of bed when requested, confirming the deficiency in care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 829 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Akron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Village Skilled Nursing & Rehabilitation Ltd | 2.9 mi | ★★★★★ | 0 | 0 |
| Pebble Creek Healthcare Center | 3.1 mi | ★★★★★ | 2 | 0 |
| Pleasant View Health Care Center | 3.7 mi | ★★★★★ | 2 | 0 |
| Barberton Post Acute | 3.9 mi | ★★★★★ | 0 | 0 |
| Chapel Hill Community | 4.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Luke Lutheran Community-portage Lakes.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.