Health inspection·May 12, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on obervation, review of video and photographic images, review of the facility assessment, review of the facility admission agreement, review of utility bills, review of vendor/supplier invoices, interview with staff, residents, facility vendors and medical supply companies and utility company representatives, the facility failed to effectively manage financial obligations required to secure the necessary resources required to ensure the ongoing appropriate delivery of care to meet the needs of the residents resulting in potential situations of resident neglect. This had the potential to affect all 132 residents residing in the facility. Findings include: On 05/01/25 at 2:11 P.M. confidential information provided to the State agency revealed concerns related to the facility not paying their bills for trash removal, thereby causing garbage to be piled up in the facility's basement and a maintenance truck full of expired foods that were unable to be removed from the property due to the lack of trash removal services. A second confidential source reported concerns to the State agency on 05/01/25 at 2:41 P.M. that the facility was unable to pay their bills. Examples provided included overflowing trash and recycling receptacles with items such as soiled briefs, food waste, and other daily trash. This source also reported garbage piled high, close to the ceiling, near the laundry room in the basement of the facility. 1. Interview on 05/05/25 at 3:15 P.M. with Certified Nursing Assistant (CNA) #302 revealed concerns that old food was being stored in a maintenance van because the compactor could no longer be used, and there was trash along the halls in the basement, piled high and putting off a foul odor, and the dumpster had been overflowing until 05/02/25. CNA #302's reported Maintenance Staff #404 moved the trash out of the basement over the course of three hours using a facility truck after the Fire Marshall told the facility it was a hazard and had to be immediately removed. During this interview, CNA #302 reported she heard concerns from other staff the facility had not been paying bills which led to the interruption in services and added that this was not the only bill that was not being paid timely. Interview on 05/06/25 from 10:37 A.M. to 10:56 A.M. with the Administrator revealed there had been a recent mix-up with trash removal which caused a delay in garbage being picked up from the facility and the trash compacter being too full to be used for a couple days. During the interview, the Administrator revealed he had been made aware of the trash removal issue the previous Sunday (04/27/25) and also revealed the Fire Marshall had come to the facility on Wednesday, 04/30/25 and directed the Page 1 of 13 365521 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0600 Level of Harm - Minimal harm or potential for actual harm facility to remove all the trash from the basement. The Administrator stated he was not 100% certain about the date, but believed a roll-off dumpster was dropped at the facility and the garbage was removed from the basement on Friday, 05/02/25. When interviewed, the Administrator denied concerns with bills being paid and stated the garbage was not stored in a resident care area (although it was in the building), so it should not have impacted the residents. Residents Affected - Many Interview on 05/06/25 at 11:00 A.M. with Maintenance #404 revealed the trash bill had not been paid, and trash began piling up in the basement hallways beginning on 05/01/25. He revealed he notified the Administrator of his concerns and when he returned to work in the facility on 05/04/25, the trash had extended down an entire wall and blocked the fire doors. He revealed this was not the first time this had happened in the facility. He confirmed the trash included items including but not limited to food waste and bodily fluids. He revealed a video which displayed numerous bags of trash lining two hallways in the basement of the facility, piled five to six bags high. Review of a picture dated 05/01/25 revealed several bags of trash in the basement hallway of the facility. Interview with Maintenance #404 confirmed the picture was an accurate picture of the accumulation of trash that had begun in the facility, though prior to it being removed, it had accumulated in a much higher capacity. Interview on 05/07/25 at 11:07 A.M. with [NAME] for Waste Management Services #552 revealed the facility held an account with them since 04/04/24. Recently services had been suspended for a high account balance, and the facility was overdue on payments. He revealed the facility continued to have an outstanding balance but was still being provided with waste management services at the time. 2. Interview on 05/07/25 at 1:20 P.M. with IGS Energy #553 revealed the facility owed a balance of $26,972.36. The last payment made by the facility was on 01/07/25. They revealed they did not have the ability to disconnect gas services as they were only a supplier of energy. However, the facility was not in good standing and could not continue to use their services until the balance was paid. Interview with the Administrator on 05/08/25 at 2:15 P.M. revealed he had no knowledge of what services were provided to the facility by IGS Energy or why there was an outstanding balance due and added that he would have to check into it. 3. Interview on 05/08/25 at 12:23 P.M. with Sipvoice #557 revealed they provided telephone services to the facility. A balance in the amount of $1513.70 was due. He revealed after two months of non-payment; a suspension notice would be issued. While he confirmed the last payment was received in March 2025, he could not confirm if a suspension notice had in fact been issued. Interview on 05/08/25 at 1:30 P.M. with Information Technology (IT) Director #399 confirmed Sipvoice provided telephone services and Verizon provided cell phone services for managers. IGS energy was a reseller of gas. Review of a bill titled Verizon dated 04/03/25 revealed a past due balance of $3086.32. 4. Interview on 05/05/25 at 3:15 P.M. with CNA #302 revealed concerns the vendor providing oxygen, and respiratory services had not been getting paid, and there was a period of time in February 2025, but she could not verify the exact dates, when the respiratory provider would not fill the facility's E tanks (three foot tall oxygen cylinders that hold approximately 680 liters of oxygen, and are often transported in carts) and the facility couldn't place any orders for oxygen or oxygen supplies 365521 Page 2 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many during that time. During the interview, CNA #302 denied knowledge of a resident running out of oxygen or not having the needed supplies, but verbalized worry that there was that chance and worried that it could happen again because she heard second-hand that the facility was behind in paying this vendor again. Telephone interview on 05/08/25 at 10:01 A.M. with Respiratory Care Partners (RCP) Representative (Rep.) #518 confirmed RCP provided oxygen and respiratory services to the facility, and all billing was handled by another vendor, Synapse. RCP Rep. #518 further confirmed services were on hold to the facility due to non-payment, but the rep. was unable to confirm the dates of service held. RCP Rep. #518 also stated their company would never remove equipment and supplies from the facility residents, but they did not fill any new orders for oxygen or equipment during the hold period. Telephone interview with Synapse Health Rep. #519 on 05/08/25 at 11:56 A.M. revealed Synapse Health was a contracted ordering platform that directly collected the money paid by the facility and passed the payment on to RCP for respiratory service provided. During the interview, Synapse Rep. #519 confirmed respiratory services were placed on hold late January 2025, and the hold was removed on 02/19/25 when the facility entered a payment plan agreement with the vendor. Synapse Rep. #519 further revealed the facility was behind on their December bill which was due 03/15/25, behind on their January bill, which was due 04/15/25, and were nearing the due date for the February bill which would be due 05/15/25. According to Synapse Rep. #529, the overdue amount was $9,526.53 with a total amount due in seven days, totaling $11,622.90 due by 05/15/25. During the interview it was reported that this was the date they would work collaboratively with RCP to decide to issue a one-week hold notice warning, meaning that the facility would receive notice that failure to make payment arrangements within one week, by 05/15/25, could result in another credit hold notice. Synapse Rep. #519 reported the facility historically waited several months between payments (payments only received August 2024, November 2024, and February 2025) so they were definitely monitoring the account very closely. Interview with the Administrator on 05/08/25 at 2:15 P.M. revealed he did not believe there was any interruption in respiratory services provided to the facility by RCP, and the facility worked with vendors whenever issues came to light to make sure no interruptions in services occurred. A follow-up interview on 05/12/25 at 2:15 P.M. with the Administrator revealed he was aware there was an issue with delayed payment to their respiratory services provider but to his knowledge, he did not believe there had been any impact on the residents and only included a hold on the facility ordering new services or equipment. 5. Interview on 05/08/25 at 9:36 A.M. with Clipboard Health #577 revealed the facility was utilizing their services for staffing purposes. They currently had a balance of $175,167.84. There were approximately four invoices overdue, and an unpaid balance existed that was more than 50 days old. The facility was on hold from using Clipboard services as of 05/07/25. Interview on 05/08/25 at 9:52 A.M. with American Medical Personnel (AMP) #556 revealed the facility had used their services in the past for staffing purposes. The facility had an outstanding balance of $42,921.74 which was due on 05/15/25. Prior to that, the facility owed approximately twice that amount, which was paid on 04/28/25. The facility was not in good standing and could not utilize the services until the balance was paid. Interview with the Administrator on 05/08/25 at 2:15 P.M. revealed the facility only used staff from three agencies: Clipboard Health, REVV Staffing, and Eshyft. When asked about the dietary aides 365521 Page 3 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many who told the surveyor they worked for a different agency, he confirmed he was unaware any other agency was currently being used for supplemental staff and stated he would have to find out who the Dietary Director was using for their staffing needs. Interview on 05/12/25 at 2:15 P.M. with the Administrator revealed the facility was aware there was a hold on staffing from Clipboard and was currently working with the staffing agency on a payment plan to reinstall services, but added the facility's goal was to maintain a good standing with the other two staffing agencies used for nursing, REVV Staffing and Eshyft. 6. Interview on 05/05/25 at 3:15 P.M. with CNA #302 revealed the facility often ran out of washcloths and she had to cut up towels earlier on this date to make eight washcloths out of one bath towel. CNA #302 reported other aides use bath towels as washcloths, but then they run out of towels too. Interview on 05/06/25 at 9:53 A.M. with Resident #71 revealed concern there were never enough washcloths and sometimes the staff provided her with a bath towel to wash with, but the wet towels made it difficult for her to clean herself due to their heaviness, so she needed the aides to provide additional assistance whenever they ran out of washcloths. Interview on 05/07/25 at 2:39 P.M. with Prime Tex #554 revealed Prime Tex supplied the facility with linens such as washcloths and reuseable underpads. The facility had bills open dating back to February 2025 in the amount of $1400.00, and they could not order more supplies until the bill had been paid. Interview on 05/07/25 at 4:50 P.M. with CNA #313 confirmed the facility ran out of washcloths all the time. CNA #313 further reported towels were used to wash residents when they ran out of washcloths, and they were a little more difficult to manipulate, but they got the job done. Interview on 05/08/25 at 3:55 P.M. with Accounts Receivable Representative #520 from Cleanslate Group, LLC. Revealed the facility just became a customer in November 2024 for the purchase of laundry chemicals but was currently on a credit hold due to delayed payment. The balance currently owed as of 05/08/25 was $3,360.21, and the facility would not be able to receive any more laundry chemicals through their company until payment arrangements were made with Cleanslate Group, LLC. A tour of the laundry room, chemical storage area, and interview with Housekeeping and Laundry Supervisor #451 on 05/08/25 at 4:25 P.M. confirmed the regular/main laundry detergent was in the blue buckets and was obtained from Cleanslate Group, the yellow bucket bleach-like chemicals came from Stockton, and the red bucket fabric softeners came from Nifty. During the tour and interview, Housekeeping and Laundry Supervisor #451 revealed the facility used approximately two to three blue buckets of detergent (supplied by Cleanslate) per week and it was confirmed there were three additional buckets, which Laundry Supervisor #451 stated was one weeks' worth of detergent, in the laundry chemical supply closet. Housekeeping and Laundry Supervisor #451 further confirmed that it was typical to maintain one additional weeks' supply on-hand and that the new order for an additional three buckets of detergent would be requested through the procurement spreadsheet request method on Friday, 05/09/25. Housekeeping and Laundry Supervisor #451was unable to say whether or not the chemicals would be obtained through Cleanslate Group. Interview on 05/12/25 at 2:15 P.M. with the Administrator confirmed he had no knowledge of Cleanslate Group, Inc. having placed the facility's order status on hold due to non-payment. During the interview, the Administrator acknowledged he would have to check to see what arrangement will be made to 365521 Page 4 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many secure laundry detergent, and the facility procurement team would be responsible for getting the laundry detergent elsewhere, if needed. 7. Interview on 05/05/25 at 3:00 P.M. with Central Supply #415 revealed the facility utilized a procurement team through another company to find vendors to fill their supply requests. According to Central Supply #415, Central Supply and the Housekeeping and Laundry Supervisor enter requests for any needed supplies, chemicals, and linens onto a spreadsheet and the procurement team picked a vendor and had the supplies shipped to the facility. During the interview, Central Supply #415 revealed the facility did not always get exactly what they ordered or needed, and the shipment was not always received timely, so sometimes orders needed placed with Amazon or Staples, or staff must go to CVS Pharmacy or Drug Mart if a supply was needed right away. Examples provided during the interview included: non-medical grade gloves when medical grade gloves were ordered, not always receiving the quantity of towels that were requested (smaller quantity), over the counter (OTC) medication being shipped in a strength that was not ordered, OTC medication in the wrong form, such as a capsule versus a coated tablet, and inability to get a wrist brace needed for a therapy resident on the short-term rehabilitation unit in a timely manner (instead, Central Supply #415 purchased at a Drug Mart using petty cash so the resident did not go without). Interview on 05/06/25 at 2:21 P.M. with the Director of Nursing (DON) revealed he had been told the former facility management company of the facility had left the facility with a lot of debt and he was hopeful the new management team was making a good effort to correct any previous billing issues. Telephone interview on 05/08/25 at 4:05 P.M. with Account Specialist #521 from Alphamed Incorporated revealed they supplied durable medical equipment (DME), such as wheelchair cushions, walker platform attachments, reachers, and exercise bands to the facility but their account was greater than 90 days overdue so their account was on a hold status and the facility could not order any more supplies until plans were made to pay the $635.35 balance. Interview on 05/12/25 at 2:15 P.M. with the Administrator revealed he was not heavily involved in the details regarding negotiating contracts and payment plans with vendors and medical suppliers because the facility used CB Services as their back-office who makes arrangements through their procurement team to secure supplies upon the facilities request. During the interview, the Administrator stated whenever there was an issue regarding payment, it was worked out, per his knowledge, behind the scenes, and if the facility could no longer get supplies from one vendor due to a payment issue, they would just order from another. Review of the facility assessment last updated on 01/25/25 revealed the facility was to determine and secure the resources necessary for residents to attain or maintain their optimal level of physical, mental, and psychosocial well-being on a day-to-day basis, as well in the event of emergency. The facility assessment further listed Clipboard as the only agency that supplemented housekeeping services and one of three agencies that provided agency/contracted nursing services as needed. Review of the facility admission agreement revealed the facility was to provide room, board, laundry, housekeeping, social, activities, nursing services, and other services and supplies required, in accordance with orders from a licensed prescribing provider. Review of the undated Residents [NAME] of Rights policy revealed residents had the right to a clean living environment, the right to receive care and services needed to meet medical treatment, nursing, comfort and sanitation needs, and the right to be free from neglect. 365521 Page 5 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/28/16, defined neglect as the failure of the facility, facility employees, or facility service providers to provide the goods and services necessary to remain free from harm, including pain, mental anguish, or emotional distress. Preventative measures were to include accurate assessment of residents' needs, analysis of the physical environment, and deployment of sufficient numbers of competent staff and resources to meet resident care needs. This deficiency represents noncompliance investigated under Master Complaint Number OH00165316 and Complaint Number OH00165311. 365521 Page 6 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure care plans were comprehensive for Residents #102 and #122. This affected two residents (#102 and #122) of six residents whose care plans were reviewed. The facility census was 132. Findings include: 1. Review of the medical record for Resident #122 revealed an admission date of 09/01/23. Diagnoses included heart disease, kidney disease, hearing loss, anxiety and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #122 was severely cognitively impaired. She required set up help for eating and oral hygiene, supervision for toileting, substantial assistance for showering and dressing and was dependent on staff for personal hygiene. She displayed physical behavioral symptoms such as hitting, kicking, pushing and scratching, verbal behaviors such as threatening and screaming at others and often rejected care. Review of the care plan dated 02/09/25 revealed no evidence the care plan addressed physical or verbal behaviors or rejection of care for Resident #122. Interview on 05/06/25 at 10:56 A.M. with Licensed Practical Nurse (LPN) #336 revealed she was responsible for creating and updating care plans for residents. She confirmed she was aware Resident #122 had some physical and verbal behaviors; she could not explain why they had not been addressed in the care plan. Interview on 05/07/25 at 10:45 A.M. with LPN #320 revealed Resident #122 had behavioral issues for at least one year. She confirmed they would attempt to calm her by using one-to-one intervention or calling her daughter to assist. She was unaware of any care planned interventions for Resident #122. Interview on 05/08/25 at 9:28 A.M. with Certified Nurse Aide (CNA) #412 revealed he had a very difficult time managing Resident #122's behaviors. She has kicked staff in the stomach, punched, scratched and left marks on other employees. He confirmed he had been given no specific instruction from Administration in regards with specific interventions to help manage her behavior. Review of the undated facility policy titled Comprehensive Care Plans revealed care plans would be reviewed and revised after each comprehensive and quarterly MDS assessment. The care plan would include measurable objectives and interventions would be documented as appropriate. 2. Review of the medical record for Resident #102 revealed an initial admission date of 02/28/25 and a re-entry date of 03/22/25 (review of the resident census revealed Resident #102 was hospitalized from [DATE] through 03/22/25). Active diagnoses included influenza with encephalopathy, urinary retention, benign prostatic hyperplasia, unspecified dementia with behavioral disturbance, anxiety disorder, congestive heart failure, stage three chronic kidney disease, chronic obstructive pulmonary disease, and altered mental status. Review of the MDS assessment completed on 03/06/25 revealed Resident #102 had moderately impaired 365521 Page 7 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cognition and no rejection of care. Further review of the MDS revealed Resident #102 required substantial assistance with personal hygiene, toileting hygiene, dressing lower extremities, and bathing. Review of the NSG-Skin and Wound Assessment dated 03/06/25 revealed a new onset deep tissue injury (DTI) (intact or non-intact skin with persistent non-blanchable red, maroon, purple, or other discoloration) to Resident #102's left heel. Review of the NSG-Skin and Wound Assessment dated 04/10/25 revealed a new onset DTI to Resident #102's right heel. Review of the Surgical Wound Care Services (SWCS) progress note dated 03/13/25 revealed the facility identified left heel DTI with onset dated 03/06/25 was determined to be an unstageable pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone). Treatment directives recommended for Resident #102 included checking for incontinence every two hours, repositioning every two hours, elevating Resident #102's bilateral heels off the bed with pillows at all times when in bed. Review of the SWCS progress note dated 04/10/25 revealed a new onset DTI to the right heel. Treatment directives recommended for Resident #102 included checking for incontinence every two hours, repositioning every two hours, and elevating Resident #102's bilateral heels off the bed and pillows at all times when in bed. Review of the SWCS progress note dated 04/17/25 revealed the DTI to Resident #102's right heel evolved into an unstageable pressure ulcer. Treatment recommendations remained as previously indicated, including offloading pressure and keeping Resident #102's bilateral heels elevated. Review of the orders revealed orders dated 03/23/25 to turn and reposition every two hours as needed and to float heels when in bed as much as possible. Review of the nursing documentation on the treatment administration record (TAR) revealed no concerns related to these orders. Review of the care plan dated 02/28/25 to 06/20/25 revealed Resident #102 had the potential for skin breakdown due to impaired mobility. Interventions included daily monitoring of Resident #102's skin during care and reporting concerns or skin abnormalities to the nurse. There was no care plan or related interventions for any of Resident #102's actual impaired skin integrity concerns. Interview on 05/07/25 at 10:06 A.M. with LPN #303 confirmed Resident #102 had unstageable pressure ulcers to both heels and was non-compliant with floating the heels or offloading pressure. During the interview, LPN #303 confirmed there was no care plan for Resident #102's actual skin impairments or the recommended interventions, which she reported as offloading pressure from heels, use of heel protectors, and turning every two hours. LPN #303 further confirmed there was no care plan in place regarding a history of refusals or non-compliance related to offloading pressure from Resident #102's heels. Review of the undated policy titled Comprehensive Care Plans revealed all care area needs identified during assessments were to be considered in the development of the person-centered comprehensive care plan and the care plan should include all interventions and services required for the resident to meet or maintain their highest practicable physical, mental, and psychosocial well-being. This deficiency represents noncompliance investigated under Complaint Numbers OH00165058, OH00165031, and OH00163700. 365521 Page 8 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, interviews, review of the shower schedule, and review of facility policy, the facility failed to provide assistance with bathing services as scheduled to Residents #67 and #102. This affected two residents (#67 and #102) of three residents who were reviewed for assistance with activities of daily living (ADL). The facility census was 132. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 06/11/19. Diagnoses included encounter for orthopedic aftercare following surgical amputation, dysphagia, anorexia, urinary incontinence, adult failure to thrive, gastrostomy status, atrial fibrillation, unspecified dementia, difficulty walking, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment completed on 02/03/25 revealed Resident #67 had severely impaired cognition and was dependent on staff for all ADL, including bathing. Review of the care plan dated 01/24/19 through 07/29/25 revealed Resident #67 had self-care deficits and required staff assistance with ADL related to functional decline and impaired mobility. Interventions included treating Resident #67 respectfully, encouraging Resident #67 to participate with care tasks, understanding resident limitations, and providing assistance and completing the ADL tasks for Resident #67 as needed. Review of the progress notes from 02/09/25 through 05/07/25 revealed no notes related to Resident #67 refusing bathing assistance. Review of the shower sheets from March 2025 revealed Resident #67 received a bed bath once weekly on Mondays between 03/05/25 and 03/26/25. Review of the shower sheets from April 2025 revealed two baths were received, one on 04/02/25 and one on 04/12/25 (Resident #67 was hospitalized from [DATE] to 04/21/25). There was no documented evidence Resident #67 was bathed since returning from the hospital on [DATE] through 04/30/25 and there was no bathing documentation for Resident #67 during May 2025 as of 05/07/25. Review of the bathing schedule revealed Resident #67 was to be bathed during the afternoon shifts twice weekly, on Wednesdays and Saturdays. Interview on 05/06/25 at 11:05 A.M. with Assistant Director of Nursing (ADON) #410 confirmed there were no showers sheets for Resident #67 for May 2025. Interview on 05/07/25 at 9:20 A.M. with Certified Nurse Aide (CNA) #352 confirmed residents were supposed to receive showers per the shower schedules kept in the shower binders, and aides were to document all bathing tasks on the sheets provided in the binders. Interview on 05/07/25 at 9:25 A.M. with CNA #513 confirmed resident bathing schedules were maintained in a bath binder and when a resident received a bed bath or a shower, the task was to be documented on the shower and skin sheets and kept in the bath binder. During the interview, CNA #513 confirmed Resident #67 was to be bathed on Wednesdays and Saturdays during afternoon shift. CNA #513 further confirmed that there was no documented evidence Resident #67 received a bath or shower during May 365521 Page 9 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0677 2025, but should have received a bath on 05/03/25. Level of Harm - Minimal harm or potential for actual harm Interview on 05/07/25 at 9:41 A.M. CNA #514 confirmed aides were to look at the shower book to see when residents were scheduled for their baths or showers and that they were supposed to document any bathing activities on the skin and shower sheets in the shower book, as well as any refusals. Residents Affected - Few Interview on 05/07/25 at 4:50 P.M. with CNA #313 confirmed the shower books were kept at the nurses' stations and contained the shower schedules for residents on each unit. She further confirmed once bathing was completed, aides were to document the bathing type/method, date, and skin condition on the shower sheets that were in the shower books. During the interview, CNA #313 confirmed any resident refusals of the bathing task were also to be documented on these forms. Review of the policy titled Bathing Residents, dated December 1998, revealed all residents were to be bathed as necessary to maintain cleanliness and stimulate circulation. Bathing was to occur at least once a week and as needed and were to be given according to a schedule. Review of the policy titled Resident Showers, dated 04/01/21, revealed showers would be given per resident request or per facility schedule protocol and partial baths may be given between regular shower schedules. The policy further revealed the facility was to assist residents with bathing to maintain proper hygiene and skin care. 2. Review of the medical record for Resident #102 revealed an initial admission date of 02/28/25 and a re-entry date of 03/22/25 (review of the resident census revealed Resident #102 was hospitalized from [DATE] through 03/22/25). Diagnoses included influenza with encephalopathy, urinary retention, benign prostatic hyperplasia, unspecified dementia with behavioral disturbance, anxiety disorder, congestive heart failure, stage three chronic kidney disease, chronic obstructive pulmonary disease, and altered mental status. Review of the admission MDS assessment completed on 03/06/25 revealed Resident #102 had moderately impaired cognition with no behaviors or rejection of care. Further review of the MDS revealed Resident #102 required substantial assistance with personal hygiene, toileting hygiene, dressing lower extremities, and bathing. Review of the care plan dated 02/28/25 through 06/20/25 revealed Resident #102 had a self-care deficit related to influenza with encephalopathy. Interventions included treating Resident #102 with respect, encouraging Resident #102 to participate with own care tasks, providing step by step prompts and not rushing care, and providing assistance and completing the ADL tasks for Resident #102 as needed. Review of the shower sheets from March 2025 revealed Resident #102 was offered a shower or bed bath twice weekly in March and refused on 03/01/25, 03/08/25, and 03/25/25 (Resident #102 was in the hospital from [DATE] to 03/22/25). In April 2025, Resident #102 received shower assistance from the therapy department on 04/02/25, received a shower on 04/08/25, and received a bed bath on 04/18/25. There was no documented evidence of Resident #102 being offered a shower or bed bath between 04/19/25 and 05/07/25. Review of the unit shower schedule revealed Resident #102 was to be bathed during afternoon shift, twice a week, on Mondays and Fridays. 365521 Page 10 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/06/25 at 11:05 A.M. with ADON #410 confirmed there were no showers sheets for Resident #102 for May 2025, and that the last documented shower for Resident #102 she could find in April 2025 was 04/18/25. Interview on 05/07/25 at 9:20 A.M. with CNA #352 confirmed residents were supposed to receive showers per the shower schedules kept in the shower binders, and aides were to document all bathing tasks on the sheets provided in the binders. Interview on 05/07/25 at 9:25 A.M. with CNA #513 confirmed resident bathing schedules were maintained in a bath binder and when a resident received a bed bath or a shower, the task was documented on the shower and skin sheets and were kept in the bath binder. During the interview, CNA #513 confirmed Resident #102 was to be bathed on Mondays and Fridays during the afternoon shift. CNA #513 further confirmed there was no documented evidence that Resident #102 had any baths or showers provided yet in May 2025, but was supposed to have been bathed on 05/02/25 and 05/05/25. Interview on 05/07/25 at 9:41 A.M. with CNA #514 confirmed aides were to look at the shower book to see when residents were scheduled for their baths or showers and that they were supposed to document any bathing activities on the skin and shower sheets in the shower book, including resident bathing refusals. Interview on 05/07/25 at 4:50 P.M. with CNA #313 confirmed the shower books were kept at the nurses' stations and contained the shower schedules for residents on each unit. She further confirmed once bathing was completed, aides were to document the bathing type/method, date, and skin condition on the shower sheets that were in the shower books and note resident refusals on the same form and notify the nurse. Review of the policy titled Bathing Residents, dated December 1998, revealed all residents were to be bathed as necessary to maintain cleanliness and stimulate circulation. Bathing was to occur at least once a week and as needed and were to be given according to a schedule. Review of the policy titled Resident Showers, dated 04/01/21, revealed showers would be given per resident request or per facility schedule protocol and partial baths may be given between regular shower schedules. The policy further revealed the facility was to assist residents with bathing to maintain proper hygiene and skin care. This deficiency represents non-compliance investigated under Complaint Number OH00165031. 365521 Page 11 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure staffing information was posted timely. This had the potential to affect all 132 residents in the facility. Residents Affected - Many Findings include: Observation on 05/05/25 at 10:23 A.M. revealed the daily posted staffing information was posted for 05/04/25. Interview at the time of the observation with the Director of Nursing (DON) confirmed the daily staffing information posted was for 05/04/25 and had not yet been updated for the current day. This deficiency is an incidental finding identified during the complaint investigation. 365521 Page 12 of 13 365521 05/12/2025 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, record review, interview and facility policy review, the facility failed to maintain a clean and sanitary environment. This affected 33 residents (#2, #5, #6, #15, #20, #28, #34, #37, #38, #39, #41, #47, #51, #52, #53, #56, #68, #73, #74, #78, #79, #80, #86, #92, #95, #98, #116, #118, #119, #120, #122, #124 and #125) on the memory care unit and had the potential to affect all 132 residents in the facility. Findings include: Observation on 05/05/25 at 9:26 A.M. of the memory care unit revealed two ceiling tiles in the common area living room removed and a red bucket on the floor underneath. Interview with Certified Nurse Aide (CNA) #309 at the time of the observation confirmed the ceiling tiles had been removed when she came into work, and she believed the bucket was to catch any liquids that may have been dripping. Observations on 05/05/25 at 12:45 P.M. of the laundry area revealed a brown substance on two of the ceiling tiles covering approximately 40 percent of each tile. Three other tiles were bulging from the frame. A pipe was coming from a ceiling tile into a bucket with approximately one inch of brownish liquid. Observation on 05/06/25 at 8:00 A.M. revealed the ceiling tiles in the memory care common area living room remained removed, with the bucket now placed against the wall. Interview on 05/06/25 at 11:00 A.M. with Maintenance #404 confirmed the ceiling above the memory care unit had been leaking and was an ongoing issue. Interview on 05/06/25 at 3:39 P.M. with Housekeeping and Laundry Supervisor #451 confirmed the boiler system caused leaks in the ceiling which created the brownish substances and bulging of the ceiling tiles. He confirmed clean resident laundry could be affected if any leakage came in contact with the laundry. Review of the facility policy titled Safe and Homelike Environment, dated 04/01/20, revealed the facility would provide a safe, clean and homelike environment including but not limited to areas such as activity areas, room, hallways and resident rooms. This deficiency represents noncompliance investigated under Master Complaint Number OH00165316 and Complaint Numbers OH00165313 and OH00165031. 365521 Page 13 of 13