Health inspection·November 29, 2018

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an allegation of neglect, involving Resident #186 was thoroughly investigated. This affected one resident (Resident #186) of two residents reviewed for abuse and neglect. Residents Affected - Few Findings include: Record review revealed Resident #186 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea, chronic obstructive pulmonary disease, hypoxemia and anxiety. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/18 revealed the resident was cognitively intact and required the extensive assistance of two staff for her activities of daily living. The resident was discharged from the facility to her home on [DATE]. Review of a facility self reported incident, dated 06/03/18 revealed Resident #186 alleged a State tested nursing assistant did not answer her call light within a reasonable time period around 3:00 A.M. Review of the facility investigation of the incident revealed the investigation did not include an interview with the resident or details of her allegation, including care that was not provided or the actual time it took for her call light to be answered. In addition, other residents were not interviewed. The investigation contained a statement from a supervisor, who indicated she was unaware of the resident concerns, but did not contain statements from any staff who cared for the resident on 06/03/18 or any other time. Review of the investigation did reveal a report of a call light audit of the resident's room on 06/03/18 indicating her call light rang in the bathroom on that night from 2:31 A.M. until 2:36 A.M. (5 minutes and 40 seconds), from 3:53 A.M. until 3:55 A.M. (1 minute and 44 seconds) and from 5:18 A.M. until 5:21 A.M. (2 minutes and 45 seconds). All calls were from the resident's bathroom. Review of a more thorough call light audit for the resident room revealed call light response time as long as 14 minutes on 06/02/18 at 6:02 A.M. An interview with the Administrator on 11/28/18 at 2:45 P.M. revealed he had completed the investigation of the incident. He stated he could not remember the details of the investigation, including who had reported the resident's concern to him. He stated it may have been the resident's daughter, with whom he had contact frequently. He stated he performed a check of the automated call light system for 06/03/18 and found the call light was answered within five minutes, so he did not pursue the concern further, as he considered that a reasonable call light response time. He verified the investigation did not indicate how long the resident felt she had waited, if her needs were attended to by staff or any other details about the concern. He verified if the resident had been assisted to the bathroom at 2:30 A.M. and had to wait for 5 minutes to be assisted back to bed, although the time did not seem excessive, the resident might have had concerns if the staff member helping her had not been available promptly, knowing the resident was in the bathroom already. He also verified there was no exact indication of the date of the resident's alleged concern through an interview and the thoroughness of the investigation could not be confirmed as the source of the complaint and exact allegations of the concern and who it had been reported to had not been recorded. Review of the facility Abuse policy, revised January 2018 revealed all allegations of abuse, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 2 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 0610 including mistreatment neglect or abuse, would be promptly and thoroughly investigated and reported timely to the State survey agency. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 3 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #45's fall interventions were in place as ordered. This affected one resident (Resident #45) of one resident reviewed for accident hazards. Findings include: Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including fracture of upper end of left humerus, psychosis, vascular dementia with behavioral disturbance, muscle weakness, and history of falling. Resident #45's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/18 revealed his cognition was severely impaired and he required extensive two person assistance for bed mobility and transfers. Resident #45's physician's order, dated 04/05/18 revealed the resident's bed should be in low position. Resident #45's active comprehensive care plan for being at risk for falls revealed an intervention of bed in lowest positioning. Observation on 11/27/18 at 9:05 A.M. revealed Resident #45 was in his room by himself. The resident was laying flat in bed with his bed at a waist high level position. State Tested Nursing Assistant (STNA) #800 and STNA #801 were observed to walk down the hall and entered Resident #45's room. Interview on 11/27/18 at 9:09 A.M. with STNA #800 revealed Resident #45's bed was not in a low position when she entered the room, and verified the bed was about waist high. STNA #800 revealed Resident #45's bed should be in low position when no one was in the room with him. Interview on 11/27/18 at 9:16 A.M. with STNA #801 revealed Resident #45's bed height was in a medium position. STNA #801 revealed she was responsible for leaving Resident #45 in the higher bed position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 4 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement a comprehensive and individualized pain management program to adequately manage Resident #118's pain. This affected one resident (Resident #118) of one resident reviewed for pain. Residents Affected - Few Findings include: Record review revealed Resident #118 was admitted to the facility on [DATE] with diagnoses including quadriplegia, generalized anxiety disorder, major depressive disorder, muscle spasms, constipation, chronic pain due to trauma, and dislocation of C6/C7 vertebrae. Resident #118's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was intact and he was totally dependent on two staff for bed mobility, transfers, toileting, and dressing. Resident #118's medical record revealed on 10/18/18 he was admitted to the hospital for constipation. Resident #118's physician orders prior to being admitted to the hospital revealed he was ordered Morphine sulfate contin 15 milligrams every eight hours as needed for pain and Lyrica 200 milligrams, one time a day at bedtime for chronic pain. Resident #118's hospital discharge instructions revealed the resident should stop taking the Morphine sulfate contin and continue taking Lyrica 200 milligrams at bedtime. Resident #118's next dose of Lyrica was due on 10/22/18 at 9:00 P.M. Resident #118's physician orders upon readmission revealed he was ordered Lyrica 200 milligrams at bedtime for chronic pain and Acetaminophen 325 milligrams, give 650 milligrams by mouth every four hours as needed for pain. Resident #118's admission assessment dated [DATE] revealed the resident did not complain of pain and the nurse practitioner stated that the resident needed to follow up with his pain management doctor. Resident #118 was reminded to ask for pain medications when in pain, and reviewed routine and as needed pain medications with the family. Resident #118's re-admission pain assessment dated [DATE] revealed he had frequent moderate pain. Resident #118's October 2018 Medication Administration Record (MAR) revealed on 10/22/18 at 9:00 P.M. and on 10/23/18 at 9:00 P.M. the Lyrica was held and to see nurses note. Resident #118's eMAR progress note dated 10/22/18 at 9:09 A.M. revealed they were awaiting pharmacy. Resident #118's medical record contained no corresponding progress note for holding the Lyrica on 10/23/18 at 9:00 P.M. There was no evidence in Resident #118's medical record that it was discussed with the resident that his Lyrica medication was on hold. Resident #118's October 2018 MAR revealed a pain assessment completed every eight hours was started on 10/23/18 at 8:00 A.M. On 10/23/18 it was documented that the resident did not have any pain at 8:00 A.M. or 4:00 P.M. on 10/24/18 he had no pain at 12:00 A.M., a pain level one out of ten at 8:00 A.M., and no pain at 4:00 P.M. On 10/25/18 at 12:00 A.M., a pain level five out of ten, no pain at 8:00 A.M., and a pain level five out of ten at 4:00 P.M. On 10/26/18 the resident's pain level was zero out of 10 for all three assessment times. On 10/27/18 his pain level was zero out of ten at 12:00 A.M. and 8:00 A.M., and a eight out ten at 4:00 P.M. On 10/28/18 his pain level was zero out of ten (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 5 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for all three assessments. On 10/29/18 his pain level was zero out of ten at 12:00 A.M. and 8:00 A.M. and one of ten at 4:00 P.M. On 10/30/18 and 10/31/18 the residents pain was zero out of 10 for all three assessments. Resident #119's Health Status Note dated 10/23/18 at 6:32 A.M. revealed he complained of abdominal pain at a level six out of ten. Resident #119's Health Status Note dated 10/23/18 at 10:11 A.M. revealed a call was placed with the resident's pain management physician and the power of attorney (POA) wanted the resident back on Morphine sulfate contin 15 milligrams, once a day as needed. Resident #118's Health Status Note dated 10/23/18 at 11:32 A.M. revealed the resident wanted his as needed pain medication, and the resident was educated on not having any orders for narcotics at this time. Resident #118 stated to the nurse to call his sister and get his pain pills, that he needed them, he felt better but needed his pain pills. A call was placed to the POA to update on the resident's request for pain medication. Resident #118's Health State Note dated 10/23/18 at 12:00 P.M. revealed his pain management doctor was attempted to be contacted again and his POA indicated he had an appointment with the pain management doctor on 10/29/18. Resident #118's Health Status Note dated 10/23/18 at 1:25 P.M. revealed a call was placed to Certified Nurse Practitioner (CNP) #802 with the residents request for as needed pain medication. The following note at 2:21 P.M. revealed Resident #118 told the nurse he wanted to go to the hospital, he needed his pain medication, he could get it in the hospital, he was in pain, and wanted to go to hospital. A call was placed to CNP #802 and an order was obtained to send the resident to the emergency for evaluation per his request. The following note at 2:34 P.M. revealed Resident #118 wanted to speak to the CNP and wanted an explanation on why the medical doctor would not give him any as needed pain medication, and another call was made to CNP #802. Resident #118's Health Status Note dated 10/23/18 at 3:30 P.M. revealed CNP called facility and asked if resident had Lyrica order in place, and the charge nurse explained that the family refused the medication in the hospital and wanted as needed pain medication ordered. Resident #118 was then ordered Tramadol 50 milligrams three times a day for pain starting at 9:00 P.M. Resident #118's physician orders dated 10/24/18, revealed the resident's Lyrica was discontinued. There was no evidence in the medical record that this was discussed with the resident. Resident #118's Health Status Noted dated 10/27/18 9:27 P.M. revealed a message was left for CNP per sister/resident request to start Lyrica due to uncontrolled pain. The next note at 9:45 P.M. revealed the resident was ordered Lyrica 200 milligrams at bedtime daily. Resident #118's Health State Note dated 10/29/18 revealed the pain management physician discharged the resident from pain management services. Resident #118's POA and CNP #802 were updated. CNP #802 revealed the resident needed to find a new medical doctor for pain management. Resident #118's Health Status Note dated 10/30/18 at 2:01 P.M. revealed the resident called the nurse into his room and told her to call CNP #802 and tell her that he was on Lyrica three times a day when he first got to the facility and now he was on once a day, and Lyrica was great, but it wore (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 6 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few off and he needed his Lyrica. A call was placed to CNP #802. The following note at 2:13 P.M. revealed the resident needed to find a pain management to follow his pain, she would not increase frequency of Lyrica per the resident's request to be increased. Resident #118's medical record contained no evidence of addressing his pain concerns further. Resident #118's Health Status Note dated 10/30/18 at 9:40 P.M. revealed the resident returned to the facility with sister and stated that while they were out to dinner, resident complaints of severe nerve pain, so he went to to the emergency room. Resident #118 then had a new order for Lyrica 200 milligrams twice a day for seven days. Interview on 11/27/18 at 12:00 P.M. with Resident #118's family revealed the facility was not managing the resident's pain effectively, resulting in her having to take him to the emergency room. Interview on 11/29/18 at 11:28 A.M. with Social Services Designee #810 revealed at Resident #118's care conference on 10/25/18 the resident did have a concern that he wanted something stronger for his pain, and he ended up going to the emergency room to get it. Interview on 11/29/18 at 11:45 A.M. with Resident #118 and his family revealed when the resident was on Morphine sulfate and Lyrica, the facility reduced the Lyrica because they could not touch the Morphine because it it was prescribed by the pain management physician, so he was taking it once a day before being hospitalized on [DATE]. Upon return to the facility on [DATE], the facility didn't give him any Lyrica, and then when he had it and they asked to increase it because the resident's nerve pain was bad, the nurse practitioner would not do it, therefore the family member took the resident to the hospital to get the Lyrica increased. Resident #118 and his family could not recall the resident refusing the medication in the hospital and was not sure why Resident #118 was not administered Lyrica upon readmission to the facility. Interview on 11/29/18 at 12:53 P.M. with CNP #802 revealed prior to Resident #118 going out to the hospital on [DATE] the facility had a meeting about concerns that Resident #118 was hallucinating and the resident did not want to touch the Morphine so everyone agreed to reduce the Lyrica. CNP #802 revealed the resident refused the Morphine and Lyrica at the hospital and wasn't on anything for pain, so he had stopped the Lyrica on his own. CNP #802 revealed she did not think the facility continued the Lyrica upon his readmission on [DATE] but did end up putting him back on it at night, as the resident said the neuropathy was a problem at night and not in the day. CNP #802 revealed she would not increase the Lyrica due to the concern about hallucinations and him saying the medication at night was okay, therefore she referred him to pain management. Interview on 11/29/18 at 2:49 P.M. with Director of Nursing (DON) revealed upon Resident #118's readmission on [DATE] they did not have a prescription for Lyrica, and the the nurse practitioner would not write the prescription, and referred the resident to pain management. The DON confirmed there was no evidence the facility discussed the resident not wanting Lyrica upon admission on [DATE]. The DON confirmed the CNP would not increase the Lyrica upon the residents request, therefore the resident went to the hospital to get it increased. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 7 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain sufficient levels of nursing staff to ensure call lights were answered timely and to meet the total care needs of all residents. This affected 13 residents (Resident #12, #13, #25, #33, #40, #71, #73, #74, #77, #84, #85, #118 and #120) and had the potential to affect all 134 residents residing in the facility. Findings include: 1. During the annual survey, the following residents identified concerns related to staffing: Interview on 11/26/18 at 10:36 A.M. with Resident #71 revealed the resident felt the facility needed more staff because she had incidents in which she had to to sit on the toilet too long. Interview on 11/26/18 at 10:50 A.M. with Resident #74 revealed sometimes she has to wait 40 minutes for her call light to get answered, more on second shift, and she had been left on the bed pan for two hours a couple months ago. Interview on 11/26/18 at 2:40 P.M. with Resident #84 revealed the facility was short on staff in the evening and call light response was delayed due to staffing. Interview on 11/26/18 at 2:48 P.M. with Resident #77 revealed there was a delay in call response and that it could take 45 minutes to an hour for staff to respond on second and third shift. Interview on 11/26/18 at 2:50 P.M. with Resident #85 revealed in the morning and night she waits a half hour or all day to go to the bathroom, resulting in sometimes having to go out of her room and get some help. Interview on 11/27/18 at 9:21 A.M. with Resident #33 revealed sometimes he has to wait 20 to 25 minutes on night shift to get help. Interview on 11/27/18 at 11:55 A.M. with Resident #118's family member revealed the resident has had to wait one hour at night for help and he has had to use his electronic wireless calling system to call his family to contact the facility to go and help him. 2. Observation on 11/26/18 at 11:43 A.M. revealed Resident #120's call light had been activated. It was unclear when it was initially activated. The call light was answered at 12:07 P.M., 24 minutes later. Review of Resident #120's Device Activity Report for 11/26/18 revealed his call light was activated at 11:30 A.M. and cleared at 12:10 P.M., 39 minutes later. Interview on 11/27/18 at 10:59 A.M. with Resident #120 revealed when he pushed his call light it took staff a little while to answer it, like when he needed [NAME]. Resident #120 revealed sometimes he has to wait an hour for staff to respond to his needs. The resident stated this didn't happen often but could happen at any time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 8 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 3. Observation on 11/26/18 at 11:51 A.M. revealed Resident #40's call light had been activated. It was unclear when it was first activated. The call light was answered at 12:06 P.M., 15 minutes later. Five facility employees were observed assisting residents with eating in the dining room, and one employee was passing trays in the halls at the time the call light was activated. Review of Resident #40's Device Activity Report for 11/26/18 revealed her call light was activated at 11:38 A.M. and was cleared at 12:09 P.M., 30 minutes later. 4. Review of the resident council minutes, dated 11/19/18 revealed the resident's present at the meeting spoke with the Director of Nursing regarding concerns they has related to call light response times. The residents were informed that call light response time would be audited. On 11/28/18 beginning at 1:59 P.M. a resident group meeting was held. During the meeting, Resident #71, Resident #12, Resident #13, Resident #84, Resident #73 and Resident #25 revealed their call lights were not answered timely. Resident #71 provided a specific example that she almost transferred herself from her wheelchair to her chair on 11/28/18 because the call light response was so delayed. Resident #84 provided a specific example that her call light response time was delayed and she sustained a fall because of it recently (actual date not provided). Review of Resident 71's Device Activity Report for 11/28/18 revealed her call light was activated at 12:42 P.M. and was cleared at 11/28/18, 76 minutes later. Review of Resident #84's Device Activity Report for 11/24/18, the day she last fell, revealed her call light was activated at 10:11 A.M. and cleared at 10:39 A.M., 28 minutes later. Interview on 11/29/18 at 2:11 P.M. with the Administrator confirmed the delayed call light response times on the Device Activity tracker as noted above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 9 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance and hypertensive heart disease with heart failure. Resident #45's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/18 revealed his cognition was severely impaired and he required extensive two person assistance for bed mobility and transfers. Residents Affected - Few Resident #45's active comprehensive care plan for congestive heart failure revealed an intervention to give cardiac medications as ordered. Resident #45's physician orders dated 08/23/18 revealed he was ordered Isordil titradose, 15 milligrams, by mouth two times a day for heart failure. The order indicated the medication should be held if the resident's systolic blood pressure was less than 110. Review of Resident #45's November 2018 Medication Administration Record (MAR) revealed the Isordil titradose medication was not held on 11/05/18 at 9:00 P.M. with his blood pressure at 102/68, on 11/06/18 with his blood pressure at 108/78, on 11/08/18 at 9:00 P.M. with his blood pressure at 105/87, on 11/20/18 at 9:00 P.M. with his blood pressure at 106/68, on 11/22/18 at 9:00 P.M. with his blood pressure at 99/55, on 11/24/18 at 9:00 A.M. with his blood pressure at 103/70, on 11/24/18 at 9:00 P.M. with his blood pressure at 109/72, or on 11/25/18 at 9:00 P.M. with his blood pressure at 107/57. Interview on 11/28/18 at 3:43 P.M. with Registered Nurse (RN) #732 revealed there was no evidence Resident #45's Isordil titradose medication was held as ordered on the above dates when his blood pressure was outside the parameters for administration. Based on record review and interview the facility failed to ensure medications were only administered when within the physician ordered parameters for administrations. This affected two residents (Resident #93 and #45) of six residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #93 revealed an admission date into the facility on [DATE]. The diagnosis listed included primary hypertension, history of stroke, mitral valve prolapse and vascular dementia. The resident was placed under the services of palliative care on 11/21/18. Medical record review was completed for Resident #93 and revealed the physician had written an order for the administration of the medication Amlodipine Besylate tablet, 2.5 milligrams (mgs) by mouth one time a day for hypertension (high blood pressure) with parameters to hold for a systolic blood pressure (top number of the blood pressure reading) of less than 115. The start date for this order was 09/21/18. The common nursing practice was for the nurse or resident care aide to obtain the blood pressure prior to the administration of the blood pressure medication and administer the medication only if the residents blood pressure was within the ordered parameters. Review of the medication administration record for Resident #93 for the period 10/01/18 through 11/28/18 revealed the nursing staff had documented administration at approximately 9:00 A.M. each morning with the following blood pressures recorded prior to administration: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 10 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 0757 On 10/03/18 the blood pressure recorded was 112/60 and the medication was administered. Level of Harm - Minimal harm or potential for actual harm On 10/04/18 the blood pressure recorded was 106/58 and the medication was administered. On 10/14/18 the blood pressure recorded was 112/64 and the medication was administered. Residents Affected - Few On 10/15/18 the blood pressure recorded was 110/73 and the medication was administered. On 10/16/18 the blood pressure recorded was 110/66 and the medication was administered. On 10/17/18 the blood pressure recorded was 112/62 and the medication was administered. On 10/18/18 the blood pressure recorded was 100/56 and the medication was administered. On 10/19/18 the blood pressure recorded was 110/62 and the medication was administered. On 10/20/18 the blood pressure recorded was 110/64 and the medication was administered. On 10/22/18 the blood pressure recorded was 108/68 and the medication was administered. On 10/23/18 the blood pressure recorded was 110/52 and the medication was administered. On 10/24/18 the blood pressure recorded was 99/67 and the medication was administered. On 10/25/18 the blood pressure recorded was 100/60 and the medication was administered. On 10/26/18 the blood pressure recorded was 104/60 and the medication was administered. On 10/27/18 the blood pressure recorded was 1104/64 and the medication was administered. On 10/28/18 the blood pressure recorded was 112/72 and the medication was administered. On 10/30/18 the blood pressure recorded was 102/58 and the medication was administered. On 10/31/18 the blood pressure recorded was 98/60 and the medication was administered. On 11/01/18 the blood pressure recorded was 102/60 and the medication was administered. On 11/02/18 the blood pressure recorded was 104/66 and the medication was administered. On 11/05/18 the blood pressure recorded was 102/60 and the medication was administered. On 11/07/18 the blood pressure recorded was 100/62 and the medication was administered. On 11/09/18 the blood pressure recorded was 10/60 and the medication was administered. On 11/19/18 the blood pressure recorded was 108/60 and the medication was administered. These findings were verified with the Director of Nursing on 11/29/18 at 10:35 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 11 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 0757 Level of Harm - Minimal harm or potential for actual harm An interview on 11/29/18 at 10:55 A.M. with Registered Nurse (RN) #500 who had initialed the medication administration on the mornings when the blood pressure was not within proper parameters, verified she had administered the medication on the dates identified and could not sate any reason why she had administered the medication when the systolic blood pressure was not within proper administration range according to the physician orders. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 12 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure consistent infection control measures were in place to to manage Resident #109's urinary tract infections. This affected one resident (Resident #109) of two residents reviewed for urinary tract infections. Residents Affected - Few Findings include: Record review revealed Resident #109 was re-admitted to the facility on [DATE] with diagnoses including arthropathy, multiple fractures of ribs, difficulty walking and major depressive disorder. Resident #109's Health Status Note, dated 09/20/2017 revealed the resident had increased confusion, and her daughter wanted a urine dip. The following note on 09/21/17 revealed her urine was positive for blood and leukocytes, the urine was cloudy with foul odor, the resident had to urinate more than usual and a urine sample was obtained. On 09/24/17 she was started on an antibiotic for seven days. Resident #109's medical record contained no evidence she her urine was retested or that she was placed on isolation precautions. Resident #109's laboratory results reported 09/24/17 revealed she had escherichia coli extended-spectrum beta-lactamase of the urine. Resident #109's Health Status Notes revealed she was discharged on 01/06/18 and re-admitted to the facility on [DATE] with pneumonia and a urinary tract infection and was on two antibiotics. Resident #109's was on an antibiotic for ESBL and a urinary tract infection. Resident #109's Health Status Note dated 01/15/18 revealed the residents antibiotic therapy was completed and the nurse practitioner was paged regarding discontinuing contact precautions or to repeat a urine analysis. Resident #109's physician orders, dated 01/15/18 revealed the resident was ordered a repeat urine analysis. Resident #109's physician orders revealed on 01/17/18 the residents contact isolation precautions were discontinued. Resident #109's laboratory results reported 01/18/18 revealed there was no significant growth in her urine and a culture and sensitivity analysis was not completed. Resident #109's Health Status Note, dated 10/20/18 revealed the resident stated she was urinating more frequently, with burning and urgency. A urine dip was completed and it was positive for leukocyte, nitrite, protein, and blood. The certified nurse practitioner was called and and new orders were received for urine analysis and culture and sensitivity. Resident #109's laboratory results reported 10/25/18 revealed she had escherichia ESBL of the urine and was then started on an antibiotic. Resident #109's physician orders revealed she was ordered contact isolation precautions on 10/25/18 due to extended-spectrum beta-lactamase (ESBL) of the urine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 13 of 14 Printed: 05/15/2026 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 365020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 2116 Dover Center Rd Westlake, OH 44145 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident#109's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed her cognition was moderately impaired, she was frequently incontinent of urine and required one person extensive assistance for bed mobility, transfers and toileting. Observation on 11/24/18 at 2:41 P.M. revealed there was a cart full of personal protective equipment outside of Resident #109's room. Interview with Resident #109 at this time, revealed she had an infection but it had cleared up and did not know why the cart was in front of her door. Interview on 11/28/18 at 9:38 A.M. with Licensed Practical Nurse (LPN) #811 confirmed Resident #109 was placed on contact isolation precautions for ESBL of the urine. LPN #811 revealed the resident was not symptomatic, and was unsure why she was still on precautions. LPN #811 contacted Certified Nurse Practitioner (CNP) #815 and the CNP questioned a urine analysis not being done, and said she was still on precautions because a urine analysis needs to be ordered. Interview on 11/28/18 at 9:52 A.M. with CNP #815 revealed the facility typically completed a urine analysis when an antibiotic was finished and a urine analysis for Resident #109 may have been missed. CNP #815 revealed the facility just puts it the laboratory test in and she does not have to order it. Interview on 11/28/18 at 10:43 A.M. with Registered Nurse (RN) #732 revealed Resident #109 was on precautions from 09/21/17 until January 2018. When the laboratory test was completed in January 2018, the urine was negative therefore a culture and sensitivity was not completed, so she was taken off precautions based on that. RN #732 revealed a culture and sensitivity analysis should have been completed. Since the resident was colonized, her urine should not be retested. RN #732 was unsure why the CNP would order a urine analysis now. RN #732 revealed they follow the Centers for Disease Control recommendations for precautions and that was very vague. RN #732 revealed if a resident was not cognitively intact and required assistance with toileting, like Resident #109, they remain on isolation precautions. Interview on 11/29/18 at 2:54 P.M. with RN #732 revealed Resident #109 did not have a physician order for isolation precautions in September 2017, and she was placed back on isolation precautions on 01/06/18 until 01/17/18. Review of the facility policy, Management of MDRO-ESBL in Urine, revised April 2017, revealed review of sensitivity would determine the appropriate antibiotic if treatment was considered. Repeat testing of urine would be done after treatment per recommendation of the primary practitioner. Residents that were determined to be colonized, due to multiple positive culture results would be removed from contact precautions if they were independent with toileting and were cognitively intact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 14 of 14