Inspection·August 24, 2023

F 0604 from in front of him. Level of Harm - Minimal harm or potential for actual harm Review of the facility education record dated 08/10/23, three days after the documented incident of a restraint being used, revealed facility staff were in-serviced on restraints and interventions that included any intervention put in place for a resident must improve mobility and cannot prevent normal activities of daily living and residents had a right to fall. Residents Affected - Few Interview on 08/22/23 at 4:30 P.M. with STNA #506 revealed Resident #64 could not remove a tray table if he was lying flat in the bed. Observation of demonstration of Resident #64, with STNA #506 present, revealed he was unable to follow commands or push the tray table away. Interview on 08/23/23 at 11:08 A.M. with STNA #504 revealed Resident #64 required total care and use of a Hoyer (mechanical) lift. STNA #504 revealed Resident #64 would not be able to remove a tray table from over him. Interview on 08/23/23 at 11:12 A.M. with LPN #505 revealed Resident #64 required total care and was unable to hold a conversation with staff or other residents. LPN #505 revealed Resident #64 had a lot of safety measures in place due to history of falls. LPN #505 revealed Resident #64 was non-weight bearing and if he attempted to get out of bed, he would end up on the floor. LPN #505 revealed Resident #64 did not have enough strength to remove a bedside table if he was lying in bed. LPN #505 revealed most of Resident #64's falls resulted from trying to get out of bed. Interview on 08/23/23 at 4:50 P.M. with LPN #808 revealed Resident #64 required total care for ADL and would not be able to move a tray table from over him while lying down. LPN #808 revealed Resident #64 was unable to follow commands or conversation. Interview with the Director of Nursing (DON) on 08/23/23 at 8:29 A.M. confirmed the above findings. Interview on 08/24/23 at 9:46 A.M. with UM #501 revealed Resident #64 was very confused and was only able to follow conversations and demonstrate moving the bedside table with her. UM #501 revealed she was not present during the use of the restraint. Random observations of Resident #64 throughout the survey period dated 08/21/23 to 08/24/23 revealed him up in his Broda (reclining) chair, unable to communicate with staff or other residents, requiring complete assistance with meals, and unable to ambulate, transfer, or be repositioned without the help of staff. Resident #64 was observed slowly pushing activity blocks across the table while seated in the dining room. Review of the undated facility document titled Physical Restraints revealed the facility had a policy in place to ensure physical restraints were used appropriately. Review of the document revealed residents had a right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Further review of the document revealed for a method, device, material, or equipment to be considered a physical restraint, it must be attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body. Review of the document revealed the facility did not implement the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 2 of 11 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 08/24/2023 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 medical record review, interview, review of the fall investigations, and facility policy review the facility failed to ensure fall prevention interventions were in place to prevent falls for Resident #78 and failed to ensure falls were thoroughly investigated. This affected one resident (#78) of three residents reviewed for accidents. The facility census was 104. Findings include: Review of the medical record for Resident #78 revealed an admission date of 08/22/22. Diagnoses included Alzheimer's, muscle weakness, repeated falls, anxiety, pain, and insomnia. Review of the fall risk assessment dated [DATE] revealed Resident #78 was at high risk for falls. Review of the fall risk plan of care dated 02/20/23 revealed Resident #78 was at risk for falls due to limited mobility, muscle weakness, and a history of a right hip fracture. Interventions included anti-rollbacks to her wheelchair, Dycem (non-skid material) under her wheelchair seat cushion, non-skid footwear when out of bed, a night light in her room, perimeter mattress for positioning, offering to toilet every two to three hours, a metal reacher, and toileting at the end of each evening shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had severe cognitive impairment and required extensive assistance of one person for bed mobility and transfers, limited assistance of one person to walk in her room and was frequently incontinent of bowel and bladder. Review of the physician's orders for March 2023 revealed an order for Eliquis (blood thinner) 5 milligrams (mg) twice per day (BID). Review of the nursing note dated 03/08/23 at 9:11 A.M. revealed Resident #78 was sitting on the floor in her room, dressed in a gown with non-slip socks on, and an incontinence brief. A large, dried area of blood and tracks on the floor mixed with fresh blood on the Resident's left hand were observed. Bruising was noted to her right eyebrow, right temple, side of her face and hair. The resident was holding her right elbow and shoulder, grimacing and making verbal statements of Oww!. Her right shoulder appeared visibly displaced with visible discoloration. Her bed was in the low position, call light was attached to the right side bed rail, in reach while in bed. A body pillow was on the right side of the bed. 911 was called, and the resident was taken to the local Emergency Department (ED) where she was treated for a clavicle fracture. Resident #78 reported she was attempting to go to the bathroom when she lost her balance. A new intervention was initiated to place her bed in a low position. Review of the fall investigation dated 03/08/23 did not indicate if the resident fell from the bed or the wheelchair and if the perimeter mattress and or Dycem were in place, anti-rollbacks were in place on the wheelchair or when she was last offered to be toileted. Observation and interview on 08/24/23 at 8:15 A.M. with State Tested Nurse's Aide (STNA) #802 revealed Resident #78 did not have a perimeter mattress on her bed. She revealed it had deflated and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 3 of 11 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 08/24/2023 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 facility had not yet replaced it. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 08/24/23 at 9:46 A.M. with Licensed Practical Nurse (LPN) #809 revealed there was no night light in the resident's room. LPN #809 turned the over bed light on in Resident #78's room because she thought it was dark in the room. It is noteworthy to mention, it was storming outside at the time of the observation and notably dark outside. LPN #809 also confirmed there was no reacher available in the room, although there was a note taped to the resident's closet to remember to use her reacher. Residents Affected - Few Interview on 08/24/23 at 12:57 P.M. with the Director of Nursing (DON) verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 03/08/23. Review of the nurses note dated 05/15/23 at 5:35 A.M. revealed Resident #78 was sitting on the floor in her bathroom, in front of the toilet with her walker tilted over, brief on the floor in front of the toilet. She was wearing nonskid socks. The bathroom floor was covered in a large amount of water with an excessive amount of tissue on the toilet. She could not explain how she fell. Her vital signs were checked and found to be stable and neurological checks were initiated. The resident was encouraged to use the call light when using the bathroom. Review of the fall investigation dated 05/15/23 did not indicate if the Dycem was in place, anti-rollbacks were in place on the wheelchair, or when she was last offered to be toileted. Interview on 08/24/23 at 12:57 P.M. with the DON confirmed there were no witness statements obtained as part of the investigation, the investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 05/15/23. Review of the nurses noted dated 07/03/23 at 7:30 A.M. revealed Resident #78 was found on the floor in her room lying near her wheelchair with her walker at her feet. She was wearing nonskid socks. A laceration was noted to her upper right arm which was cleaned and covered with antibiotic ointment and gauze. The resident said she was trying to get out of bed. She was assessed for other injuries and vital signs were obtained which were within normal limits. Review of the fall investigation dated 07/03/23 did not indicate if the resident fell from the bed or the wheelchair, and if the perimeter mattress and/or Dycem were in place, anti-rollbacks were in place on the wheelchair or when she was last offered to be toileted. Interview on 08/24/23 at 12:57 P.M. with the DON confirmed witness statements were not obtained from all staff as part of the investigation, the investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 07/03/23. Review of the nurses' note dated 08/02/23 at 9:44 A.M. revealed Resident #78 was found on the floor in her room trying to go to the bathroom without assistance. Her vital signs were obtained, and she was placed back into her wheelchair with her walker out of reach. No injuries were observed. Review of the fall investigation dated 08/03/23 did not indicate if the Dycem was in place, anti-rollbacks were in place on the wheelchair, or when she was last offered to be toileted. Interview on 08/24/23 at 12:57 P.M. with the DON verified the fall investigation was not thorough (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 4 of 11 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 08/24/2023 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 and did not include if care planned interventions were in place at the time of the fall on 08/03/23. Level of Harm - Minimal harm or potential for actual harm Review of the nurse's note dated 08/04/23 at 7:00 A.M. revealed Resident #78 was found on the floor in her room in front of her wheelchair. She stated she slid out of her wheelchair. The Dycem was then placed in the wheelchair. She sustained an injury to her right elbow. Residents Affected - Few Interview on 08/24/23 at 12:57 P.M. with the DON verified the fall was not investigated, and the Dycem was not in use at the time of the fall on 08/04/23. Review of the undated facility policy titled Resident Falls revealed the facility would implement systems to minimize the likelihood of falls and falls would be reviewed to determine the potential cause. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 5 of 11 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 08/24/2023 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** Based on record review, interview, and facility policy review the facility failed to ensure a prescribed antibiotic was not given for more than 14 days without a rationale. This affected one resident (#15) of five residents reviewed for unnecessary medications. The facility census was 104. Residents Affected - Few Findings include: Review of the medical record for Resident #15 revealed an admission date of 12/11/20. Diagnoses included dry eye syndrome, anxiety, paraplegia, and corneal ulcer to the right eye. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact. She required extensive assistance of one person for transfers, bed mobility, dressing, toilet use, and hygiene. Review of the physician's orders for August 2023 revealed an order for Refresh Plus Solution one drop in both eyes four times a day (QID), Restasis 0.05 % one drop in both eyes one time a day (QD) and Moxifloxacin HCl ophthalmic drop (used to treat infections of the membrane that covers the outside of the eyeballs and the inside of the eyelids) in both eyes twice per day (BID) which began on 07/12/23. Review of the medical record revealed no evidence the physician provided a rationale for the continued use of the Moxifloxacin past 14 days. Review of the drug information located at drugs.com revealed Moxifloxacin should be used for a duration of seven days. Interview on 08/23/23 at 2:41 P.M. with the Director of Nursing (DON) confirmed there was no stop date listed or no rationale for the continued use of the Moxifloxacin. Review of the undated facility policy titled Antibiotic Stewardship-Prescribing Antibiotics revealed antibiotics would include frequency, duration and a stop date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 6 of 11 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 08/24/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure non-pharmacological interventions were utilized, failed to ensure anti-anxiety medications were used for the intended purpose and not used for longer than 14 days without a rationale. This affected three residents (#48, #71, and #94) of five residents reviewed for unnecessary medications. The facility census was 104. Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 09/26/22. Diagnoses included Lupus, psychosis, anxiety, fibromyalgia, chronic kidney disease, and arthritis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact. She was totally dependent on two people for transfers, required extensive assistance of two people for bed mobility and toilet use and extensive assistance of one person for dressing and hygiene. Review of the physician's orders for August 2023 revealed Resident #48 was ordered Ativan 0.5 (antianxiety) milligrams (mg) one tablet by mouth (PO) two times a day (BID) for anxiety and Ativan 0.5 mg every eight hours as needed (PRN) for anxiety which began 03/03/23. Review of the Medication Administration Record (MAR) for May, June, and July 2023 revealed Resident #48 received PRN Ativan on 05/27/23, 06/21/22, 06/22/23, 07/07/23, 07/11/23, 07/13/23, 07/14/23 and 07/21/23. Review of the medical record revealed no documented evidence non-pharmacological interventions were attempted prior to the administration of PRN Ativan and no documented evidence the physician provided a rationale for the continued use of Ativan. Interview on 08/23/23 at 2:50 P.M. with the Director or Nursing (DON) confirmed non-pharmacological interventions would be documented in MAR or a nursing progress note. She confirmed there was no stop date for the PRN Ativan and the physician had not provided a rationale for its continued use. Review of the undated facility policy titled Psychotropic medications revealed residents receiving psychotropic medications would be reviewed for non-pharmacological interventions and PRN psychotropic medications were limited to 14 days, unless the physician documented a rationale for continued use and indicated the duration of time the medication would be used. 2. Review of the medical record for Resident #94 revealed an admission date of 06/09/23. Diagnoses included Alzheimer's disease with late onset, dementia, anxiety disorder, depression, and insomnia. Review of the admission MDS assessment dated [DATE] revealed Resident #94 had severe cognitive impairment. The MDS assessment also indicated Resident #94 received three days of antianxiety medications during the seven-day assessment reference period. Review of the physician's orders for August 2023 identified an order for Ativan 0.5 mg every four (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 7 of 11 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 08/24/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hours PRN for anxiety and agitation. The Ativan order was dated 06/09/23 and duration was marked as indefinite. Review of Resident #94's MAR for July 2023 revealed Resident #94 received PRN Ativan seven times during the month. Review of the MAR for August 2023 revealed Resident #94 received PRN Ativan ten times during the month. Review of Resident #94's progress notes from 07/01/23 to 08/24/23 revealed no documented evidence that non-pharmacological interventions were attempted prior to administering PRN Ativan. Review of the physician progress notes for Resident #94 dated 06/13/23, 07/26/23, and 08/10/23 revealed no rational or duration indication to extend PRN Ativan order past 14-day duration. Interview on 08/24/23 at 12:15 P.M. with Unit Manager #507 confirmed Resident #94's PRN Ativan had a duration marked indefinite with no physician documentation for indication for extended duration. Unit Manager #507 further confirmed there was no documented evidence that non-pharmacological interventions were attempted prior to administration of PRN Ativan. Review of the undated policy titled Psychotropic Medications revealed non-pharmacological interventions will be used in conjunction with the psychoactive medication. PRN orders for psychotropic drugs are limited to 14 days, unless the practitioner believes that it is appropriate to extend beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN orders. 3. Review of the medical record for Resident #71 revealed an admission date of 05/20/21. Diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, unspecified psychosis, and delusional orders. Review of the quarterly MDS assessment dated [DATE] revealed Resident #71 had severely impaired cognition and other behavioral symptoms not directed toward others. The resident received antipsychotic and antidepressant medications. Review of the physician orders for August 2023 revealed Resident #71 was ordered Ativan 0.5 mg PRN for anxiety. Give 20 minutes prior to nail cutting. The order began 09/16/22. No end date was specified. Review of the MARs June, July, and August 2023 revealed Ativan 0.5 mg was given to Resident #71 on 06/08/23, 06/09/23, 06/11/23, 06/29/23, 07/06/23, 07/07/23, 07/24/23, 08/01/23, 08/13/23, and 08/21/23. Review of the medication review from the psychiatric follow-up visits on 07/06/23, 03/16/23, and 12/15/22 revealed Ativan 0.5 mg was to be given 20 minutes prior to nail cutting. Review of the nursing progress notes dated 06/08/23, 06/09/23, 06/11/23, 06/29/23, 07/06/23, 07/07/23, 07/24/23, 08/01/23, 08/13/23, and 08/21/23 for Resident #71, the dates Ativan was given, revealed no documented evidence of nail cutting. Anxiety, yelling out, resident restless yelling and screaming, increased anxiety patient yelling out, anxious; screaming out, given for yelling out and agitation, and yelling out behavior were what was noted. Non-pharmacological interventions were only documented on 06/11/23 and 7/24/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 8 of 11 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 08/24/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Interview on 08/24/23 at 3:19 P.M. with Unit Manager/Licensed Practical Nurse (LPN) #595 verified the Ativan was used PRN without an end date and non-pharmacological interventions were not consistently documented. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 9 of 11 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 08/24/2023 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 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure its facility assessment contained necessary required information. This had the potential to affect all 104 residents residing in the facility. Findings include: Review of the facility assessment dated [DATE] with a cover letter reading for the year of 2023, revealed it did not contain the following required information: • Information related to facility staffing level needs, evaluation of any contracts, memorandums of understanding including third party agreements for the provision of goods, services, or equipment to the facility during both normal operations and emergencies. • An evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff available to meet each resident's needs. • Information regarding the facility's resources which include supplies, equipment, or other services necessary to provide for the needs of residents. • Information regarding a competency-based approach to determine the knowledge and skills required among staff to ensure residents were able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. On 08/24/23 at 2:06 P.M. interview with the Administrator verified the facility assessment did not contain all the required information as noted above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 10 of 11 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 08/24/2023 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assurance (QA) Committee. This had the potential to affect all residents. The facility census was 104. Residents Affected - Many Findings include: Review of the facilities sign-in sheet for the QA meeting minutes for the meetings held on 10/19/22, 02/27/23, 04/09/23 revealed no documented evidence the medical director attended the meetings. Interview with the Administrator on 08/24/23 at 2:06 P.M. verified the medical director did not attend the QA meetings as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365020 If continuation sheet Page 11 of 11