Health inspection·January 5, 2026

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, interview, and review of the facility policy, the facility failed to ensure the privacy of Resident #118's medical record was maintained and failed to ensure privacy was maintained during care for Resident #54. This affected two residents (Resident #54 and #118) of five observed for privacy. Findings Include:1. Review of the medical record revealed Resident #118 was admitted to the facility on [DATE]. Diagnoses included diabetes mild cognitive impairment, hypothyroidism, hypertension, generalized anxiety disorder, dementia, personality disorder, peripheral vascular disease, and bipolar disorder.Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #118 had intact cognition.Observations on 12/31/25 from 9:30 A.M. to 9:35 A.M. revealed Resident #118's medical information was visible on the computer at the unattended medication cart in the hallway. The medical information listed was the residents' medications list, and identifier information with the resident's picture, name and room number. Interview and observation on 12/31/25 at 9:35 A.M. revealed Licensed Practical Nurse (LPN) #325 came out of a room down the hallway; she verified at this time she had left medical information of Resident #118 up on the computer screen unattended and she was supposed to lock the screen prior to walking away from it. Review of the facility policy titled, Confidentiality of Information and Personal Privacy, dated 11/2025 revealed the facility would protect and safeguard resident confidentiality and personal privacy. The facility would strive to protect the residents ' privacy regarding their accommodations, medical treatment, written and telephone communications, personal care, visits, and family and resident group meetings. 2. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE]. Diagnoses include anemia, hypothyroidism, chronic pain, hearing loss, viral herpes, major depressive disorder, insomnia, restless leg syndrome, rhinitis, and hypertensionReview of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition and was occasionally incontinent of bladder and always incontinent of bowel.Review of the care plan dated 09/03/25 revealed Resident #54 had incontinence and required assistance with toileting. Interventions included to encourage the resident to perform toileting and hygiene tasks about every two hours while awake, assist as necessary, encourage the resident to call for assistance as needed throughout the night, and note any changes in amount, frequency, color or odor and report any abnormalities. The care plan revealed no documentation of Resident #54 requesting to have her door open during care.Observation and interview on 12/31/25 at 9:50 A.M. revealed Agency Certified Nursing Assistant (CNA) #315 was providing incontinence care to Resident #54 with the door open and the privacy curtain was not pulled. The perineal (peri) area and buttocks of Resident #54 were visible to the hallway. When questioned at this time, Agency CNA #315 stated Resident #54 did not like her door closed but verified she could have pulled the privacy curtain around the bed to provide privacy.On 01/05/25 at 11:40 A.M. an interview with Resident #54 revealed she never told the staff to leave her door open during care. She sated most of them do close the door Residents Affected - Few Page 1 of 5 365521 365521 01/05/2026 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0583 Level of Harm - Minimal harm or potential for actual harm or at least pull the curtain around the bed.Review of the facility policy titled, Confidentiality of Information and Personal Privacy, dated 11/2025 revealed the facility would protect and safeguard resident confidentiality and personal privacy. The facility would strive to protect the residents ' privacy regarding their accommodations, medical treatment, written and telephone communications, personal care, visits, and family and resident group meetings. Residents Affected - Few 365521 Page 2 of 5 365521 01/05/2026 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of shower schedules, interview, and review of the facility policy, the facility failed to ensure personal bathing preferences were accommodated and showers were documented/completed for Resident #27. This affected one resident (#27) out of three residents reviewed for bathing.Findings Include:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included volvulus, urinary tract infection osteoarthritis, peripheral neuropathy, breast cancer, skin cancer, acute embolism of right lower extremity, and osteoporosis.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition and did not refuse care. She required moderate assistance with bathing.Review of the nurse's note dated 10/06/25 at 2:57 P.M. revealed Resident #27 refused to shower this shift, stating she would not take a shower after 7:30 A.M. Review of the nurse's note dated 12/15/25 at 2:10 P.M. revealed the Certified Nursing Assistant (CNA) entered the resident ' s room at 7:40 A.M. and the resident stated she refused to take a shower after 7:30 A.M.Review of the shower schedule revealed Resident #27 was to receive a shower on day shift on Mondays and Thursdays. The schedule did not indicate she liked to have her shower before 7:30 A.M.Review of the Task Section in the electronic charting system revealed the only shower/bath documented for December 2025 was on 12/22/25. There was no documentation of showers completed for Resident #27 from 12/01/25 through 12/21/25.On 12/31/25 at 9:56 A.M. an interview with Resident #27 revealed she did not receive a shower last week, but the staff was documenting she refused when she did not. She stated there were only two aides working so they did not do showers. She stated she liked to get her shower first thing in the morning and sometimes they did not get to her in time so she would not get it.On 12/31/25 at 3:00 P.M. an interview with the Director of Nursing (DON) revealed she was aware there was an issue with showers not being documented so she implemented a new system. She stated previously they were documenting on shower sheets however that was not always getting done so now the staff was to document in the electronic charting system under tasks. She stated she just started this documentation on 12/01/25. On 01/05/26 at 8:50 A.M. an interview with the DON revealed Resident #27 refused her showers frequently because she wanted it done before 7:30 A.M. and they could not always accommodate that. She stated they had enough staff, however, the timing was during shift change and it was difficult to get to her by 7:30 A.M., and if the staff were not there to give her shower by 7:30 A.M. she would refuse. She verified Resident #27 did not have any showers documented prior to 12/22/25.Review of the facility policy titled, Bath-Bed, dated 03/2021 revealed it was the policy of the facility to bathe residents according to their preferences to promote cleanliness and promote comfort and to observe the condition of the resident ' s skin.This deficiency represents non-compliance investigated under Complaint Number 2696584. Residents Affected - Few 365521 Page 3 of 5 365521 01/05/2026 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, observation, and facility policy review, the facility failed to ensure systems were in place to provide appropriately sized incontinence products to residents, subsequently leading to Resident #79's development of moisture-associated skin damage (MASD). Additionally, the facility failed to ensure Resident #79 was comprehensively assessed after developing MASD. This affected one resident (#79) of three residents reviewed for adequate supplies. Findings Include:Review of the medical record revealed Resident #79 admitted to the facility on [DATE]. Diagnoses included displaced bimalleolar fracture of the right lower leg, chronic obstructive pulmonary disease, rheumatoid arthritis, glaucoma, congestive heart failure, atrial flutter, vertigo, tachycardia, spinal stenosis, and insomnia.Review of the admission assessment dated [DATE] revealed Resident #79 had no skin issues. Review of the admission Braden Scale dated 11/26/25 revealed Resident #79 was high risk for pressure ulcer development.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had intact cognition, was frequently incontinent of bladder, had no skin concerns, and weighed 219 pounds.Review of the December 2025 physician's orders revealed Resident #79 had an order for weekly skin checks performed by a licensed nurse every Tuesday dated 12/02/25.Review of the plan of care dated 12/10/25 revealed Resident #79 was at risk for skin breakdown related to incontinence, age related changes and impaired mobility. Interventions included to notify the nurse of any skin abnormalities such as redness, blisters, rashes, skin tears, abrasions, bruises and any type of open area, the physician, unit manager, nursing staff, and family would be notified of any skin problems and a treatment would be initiated per orders, treat any skin condition per orders, and skin would be monitored daily when assisted with bathing, dressing, incontinence care and activities of daily living. Review of the December 2025 Treatment Administration Record revealed on 12/23/25 the weekly skin assessment for Resident #79 indicated she was red but there was no other documentation about the redness. Further review of the December 2025 physician's orders revealed Resident #79 had an order to cleanse the bilateral buttocks/sacrum with soap and water, pat dry, apply stoma powder followed by A&D ointment every shift and as needed until resolved for moisture associated skin damage (MASD) dated 12/23/25. Further review of the medical record revealed no documentation of a comprehensive skin assessment being completed of the MASD for Resident #79.Review of the nurse's notes from 12/20/25 to 12/25/25 revealed no documentation of MASD for Resident #79.On 12/31/25 at 7:40 A.M. an interview with Licensed Practical Nurse (LPN) #300 revealed the facility did not have enough briefs.On 12/31/25 at 7:45 A.M. an interview with LPN #301 revealed they rarely had larger sized briefs for the residents and had to use smaller ones on the larger residents. Observation of the rehabilitation unit supply room with LPN #302 on 12/31/25 at 8:10 A.M. revealed there were only medium and extra-large (XL) briefs in the closet. LPN #302 stated the housekeepers restocked the supply room throughout the day and the nursing assistants were able to obtain supplies from the main supply closet. On 12/31/25 at 8:40 A.M. an interview with Registered Nurse (RN) #310 revealed the facility ran out of supplies all the time. She stated they never had enough larger briefs. RN #310 stated they had two new residents who required XXXL to XXXXXL briefs and they did not have any, so they were told by management to use two XXL briefs on them. She also confirmed Resident #79 was now excoriated from briefs being too tight on her.Observation of the main supply room with Central Supply #311 on 12/31/25 at 9:40 A.M. revealed five cases of medium briefs, two cases of large briefs, one case of XXL briefs, and one case of XXXXL briefs. Central Supply #311 stated most of the residents had briefs in their rooms. She stated she ordered supplies on Monday (12/29/25), and they were delivered on Residents Affected - Few 365521 Page 4 of 5 365521 01/05/2026 Saint Luke Lutheran Home 220 Applegrove Street NE North Canton, OH 44720

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Wednesday mornings however today ' s delivery was delayed due to the weather. She stated she did not have any XL or XXXL briefs in the supply room. She stated she did not have a list of what briefs all the residents wore and the aides just told her what the residents wore when she passed the briefs out on the units. She stated she just ordered what she used the week before, confirming there was no system in place to determine how many of each size brief to order, or what size briefs each resident wore. Review of facility documentation revealed no documented evidence of a system in place when ordering supplies to determine how many of each size brief to order, or what size briefs each resident wore.On 12/31/24 at 9:56 A.M. an interview with Resident #27 revealed the facility never had enough briefs and you had to beg for them. She did not disclose what size brief she wore. On 12/31/25 at 2:35 P.M. an interview with Resident #19 revealed the facility did not have the appropriate size brief for her to wear.On 12/31/25 at 2:40 P.M. an interview with Resident #79 revealed the facility ran out of her briefs and she had to wear a smaller size which was way too tight. She stated she could not hold her urine. She stated when they ran out of her size (XXL), they used an XL and placed a medium brief inside the XL to help catch some of the urine. She stated she was getting excoriated on her bottom and groin area mostly from the brief rubbing her. She stated the staff were putting cream on her bottom now for it. On 01/05/26 at 12:30 P.M. an interview with LPN #340 stated she worked Wednesdays, Thursdays and Saturdays at the facility. She stated she completed wound rounds on Thursdays. She stated the wound grids/assessments were documented in the electronic record under assessments called the Nursing Skin Assessment. She stated Resident #79 did not have any skin issues. She stated she did not know about her having MASD and she was never told about it. She stated she would have to look at it on Wednesday (01/07/25) when she came in to work. She verified if it was MASD, it should have been assessed and documented.Review of the facility policy titled, Skin Care, dated 11/20/25 revealed the facility was to provide the necessary care to ensure residents so not to develop pressure injuries, unless clinically unavoidable. The facility provided care and services to promote the prevention of pressure injury development. It also stated to notify the wound nurse, physician or nurse practitioner, Registered Dietitian, and the resident representative upon observation of a skin change in condition. Review of the facility policy titled, Wound Care, dated 11/20/25 revealed the facility would provide therapeutic treatment to heal wounds. Wounds would be evaluated when they were observed and weekly until resolved. It would be monitored for location, size, undermining, tunneling, exudate, necrotic tissue and the presence or absence of granulation tissue and epithelialization. It also stated to notify the wound nurse for routine evaluation of the skin area until resolved. Review of the facility policy titled, Requisitioning Daily Supplies, dated 02/2008 revealed the department director must requisition needed supplies for the central supply. Supplies and equipment needed for daily use must be ordered by the department supervisors. Supervisors were responsible for maintaining daily supply levels and reordering in time to prevent running out of supplies.This deficiency represents non-compliance investigated under Complaint Number 2696584. 365521 Page 5 of 5