Health inspection·July 25, 2019

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete alleged violations involving Abuse, neglect, Misappropriation of Residents Property, Exploitation, or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and all allegations are free from retaliation or reprisal for reporting this incident. Injury of unknown source is an injury is classified as an Injury of Unknown Source when both of the following conditions are met. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular time, or the incident of injuries over time. Event ID: Facility ID: 366162 If continuation sheet Page 2 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's policy, the facility failed to report an injury of unknown injury to the state agency. This affected one (#56) of one resident reviewed for injury of unknown origin. The census was 72. Findings include: Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety. Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth. Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention included to monitor skin during baths and weekly. Review of the skin evaluations dated 07/01/19 at 2:00 P.M., revealed a skin condition, type ecchymosis treatment and monitor blisters for drainage. The medical chart was absent of any other skin evaluations. Review of nurses note dated 07/01/19 at 2:34 P.M., revealed Resident #56 has five fluid filled blisters noted to right hand on fingers with three red spots noted to right forearm. Review of physician's progress notes dated 07/02/19 at 11:00 A.M., revealed Resident #56 has fluid filled blisters on the right hand fingers. Also, has a few bumps on the right arm. Physician orders revealed orders for a rash on the arm was consistent with insect bites, to monitor and blisters are unknown cause and to monitor. Interview with the Director of Nursing #1 on 07/24/19 at 1:00 P.M., verified the origin of the blisters were unknown, there was no investigation and the injury was not reported to the state. Review of the facility's policy titled Abuse, Mistreatment, neglect, Exploitation and Misappropriation of Resident Property dated 12/11/17, revealed it is the facility's policy to investigate all alleged violations involving Abuse, neglect, Misappropriation of Residents Property, Exploitation, or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and all allegations are free from retaliation or reprisal for reporting this incident. Injury of unknown source is an injury is classified as an Injury of Unknown Source when both of the following conditions are met. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular time, or the incident of injuries over time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 3 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 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 medical record review, staff interview and review of the facility's policy, the facility failed investigate an injury of unknown origin. This affected one (#56) of one resident reviewed for injury of unknown origin. The census was 72. Residents Affected - Few Findings include: Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety. Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth. Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention included to monitor skin during baths and weekly. Review of the skin evaluations dated 07/01/19 at 2:00 P.M., revealed a skin condition, type ecchymosis treatment and monitor blisters for drainage. The medical chart was absent of any other skin evaluations. Review of nurses note dated 07/01/19 at 2:34 P.M., revealed Resident #56 has five fluid filled blisters noted to right hand on fingers with three red spots noted to right forearm. Review of physician's progress notes dated 07/02/19 at 11:00 A.M., revealed Resident #56 has fluid filled blisters on the right hand fingers. Also, has a few bumps on the right arm. Physician orders revealed orders for a rash on the arm was consistent with insect bites, to monitor and blisters are unknown cause and to monitor. Interview with the Director of Nursing #1 on 07/24/19 at 1:00 P.M., verified the origin of the blisters were unknown, there was no investigation and the injury was not reported to the state. Review of the facility's policy titled Abuse, Mistreatment, neglect, Exploitation and Misappropriation of Resident Property dated 12/11/17, revealed it is the facility's policy to investigate all alleged violations involving Abuse, neglect, Misappropriation of Residents Property, Exploitation, or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and all allegations are free from retaliation or reprisal for reporting this incident. Injury of unknown source is an injury is classified as an Injury of Unknown Source when both of the following conditions are met. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular time, or the incident of injuries over time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 4 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the ombudsman when residents were transferred or discharged from the facility. This affected two (#67 and #51) of four reviewed for hospitalization and discharge. The facility identified 64 residents who were transferred or discharged from the facility since 04/01/19. The census was 72. Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 07/03/14. Diagnoses include Dementia, Parkinson's disease and Schizophrenic. Review of the Lutheran Homes Society -[NAME] Campus, Bed Hold and leave notices dated 07/24/14 for Resident #67 representative which acknowledged they did not want a bed hold, this is the only paper which has been signed. Review of the nurse notes on 06/07/19 at 4:00 P.M. revealed Resident #67 was sent out to the hospital for evaluation per doctor for acute onset of weakness, tachycardia and unresponsiveness. Interview with Social Services #250 on 07/25/19 at 1:02 P.M. verified there are no notifications to the ombudsman of discharges of any kind but will start doing this going forward. 2. Review of Resident #51's medical record revealed an admission date of 05/10/19. Diagnoses included acute kidney failure, chronic kidney disease, heart failure, diabetes mellitus type II, chronic obstructive pulmonary disease, and major depression. Review of a transfer notice dated 06/20/19 revealed Resident #51 was sent to the emergency room due to a change in physical condition. Review of Resident #51's paper and electronic medical record revealed no evidence of a notice sent to the ombudsman of Resident #51's transfer to the hospital. Interview on 07/25/19 at 12:58 P.M. with Licensed Social Worker #250 stated she had not been sending a list of residents transferred or discharged to the ombudsman, and verified the ombudsman was not notified of Resident #51's transfer on 06/20/19. Review of the facility policy titled Bed Hold and Leave of Absence revised date 02/09 revealed the purpose of the Lutheran Home society policy on admissions to its Medicare and Medicaid certified nursing facility is to establish uniform guidelines for facility staff to follow when resident leave the facility for hospitalizations or therapeutic leave. This policy was absent of language for the facility to contact the Ombudsman of all discharges. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 5 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure bed hold notice was given to the resident or representative of transfer to the hospital. This affected one (#67) of four residents reviewed for hospitalization and discharge. The facility identified 64 residents who were transferred or discharged from the facility since 04/01/19. The census was 72. Findings include: Review of the medical record for Resident #67 revealed an admission date of 07/03/14. Diagnoses include Dementia, Parkinson's disease and Schizophrenic. Review of the Lutheran Homes Society -[NAME] Campus , Bed Hold and Leave notices upon admission dated 07/24/14 for Resident #57 was signed by the representative which acknowledged they did not want a bed hold and this is the only paper which has been signed. Review of the nurse notes on 06/07/19 at 4:00 P.M., revealed Resident #67 was sent out to the hospital for evaluation per doctor for acute onset of weakness, tachycardia and unresponsiveness. Interview with Admissions Director Liaison #260 on 07/25/19 at 12:40 P.M., verified there was not a bed hold notice given to Resident #67 upon discharge to the hospital. He had signed a paper upon admission he did not want a bed hold but was unaware he needed to receive another one when being sent to the hospital. Did not receive the document which is the policy for bed hold. Review of the facility's Bed Hold and Leave of Absence policy revised 02/09 the purpose of the Lutheran home society policy on admissions to its Medicare and Medicaid certified nursing facility is to establish uniform guidelines for facility staff to follow when resident leave the facility for hospitalizations or therapeutic leave. Under section B states at the time of transfer of a resident for hospitalization or therapeutic leave, the resident will be provided with a separate bed hold notice summarizing the facility's bed hold policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 6 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to update a care plan when a pressure reducing intervention was discontinued. This affected one (#37) of three residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The census was 72. Findings include: Review of Resident #37's medical record revealed an admission of 03/30/19. Diagnoses included dysphagia, unspecified visual loss, umbilical hernia, essential hypertension, hyperlipidemia, and chronic bronchitis. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired and was assessed with one unstageable (a localized area of tissue necrosis and can be covered by slough or eschar) pressure ulcer that was present on admission or re-entry to the facility. Review of a skin integrity care plan dated 03/30/19 revealed an intervention for Resident #37 to have pressure relieving boots on at all times except during transfers and therapy. Observations on 07/23/19 at 1:33 P.M. and 3:46 P.M., on 07/24/19 at 7:38 A.M., at 10:06 A.M., and at 1:21 P.M. revealed Resident #37 sitting in a reclining chair in her bedroom or in the common area with no pressure relieving boots on. Review of a nursing progress note dated 04/15/19 revealed an occupational therapist spoke to the assistant director of nursing about the risks and benefits of Resident #37's pressure relieving boots. Further review of the nursing progress note revealed Resident #37's pressure relieving boots were discontinued. Review of Resident #37's July 2019 physician orders revealed no order for pressure relieving boots. Interview on 07/24/19 at 4:39 P.M. with Licensed Practical Nurse (LPN) #460, verified Resident #37 had no order for pressure relieving boots, and also verified Resident #37 had not been wearing any pressure relieving boots. LPN #460 verified Resident #37's pressure relieving boots were discontinued on 04/16/19, but remained and intervention on the skin integrity care plan. LPN #460 verified the intervention should have been removed from the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 7 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 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 and staff interview, the facility failed to ensure the monitoring of blisters and bug bites on resident was monitored per physician's order. This affected one (#56) of one reviewed for skin conditions. The census was 72. Residents Affected - Few Findings include: Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety. Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth. Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention included to monitor skin during baths and weekly. Review of the skin evaluations dated 07/01/19 at 2:00 P.M., revealed a skin condition, type ecchymosis treatment and monitor blisters for drainage. The medical chart was absent of any other skin evaluations. Review of nurses note dated 07/01/19 at 2:34 P.M., revealed Resident #56 has five fluid filled blisters noted to right hand on fingers with three red spots noted to right forearm. Review of physician's progress notes dated 07/02/19 at 11:00 A.M., revealed Resident #56 has fluid filled blisters on the right hand fingers. Also, has a few bumps on the right arm. Physician orders revealed orders for a rash on the arm was consistent with insect bites, to monitor and blisters are unknown cause and to monitor. Interview with the Director of Nursing #1 on 07/24/19 at 1:00 P.M., verified there was no documentation of monitoring of the blisters or bug bites. She said the nurse aides do the skin assessments on shower days but was not able to produce evidence this occurred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 8 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facilty policy review and staff interview, the facility failed to implement a pressure reducing device to prevent pressure ulcers for a resident with a history of pressure sores. This affected one (#37) of three residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The census was 72. Residents Affected - Few Findings include: Review of Resident #37's medical record revealed an admission of 03/30/19. Diagnoses included dysphagia, unspecified visual loss, umbilical hernia, essential hypertension, hyperlipidemia, and chronic bronchitis. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired, required extensive assistance with bed mobility, and was assessed with one unstageable (a localized area of tissue necrosis and can be covered by slough or eschar) pressure ulcer that was present on admission or re-entry to the facility. Review of a physician order dated 04/02/19 revealed Resident #37 was ordered a pressure reducing cushion to her wheelchair and recliner and staff should check placement each shift. Review of a wound assessments dated between 03/30/19 and 07/24/19 revealed Resident #37 was admitted to the facility with an unstageable pressure ulcer to her left heel on 03/30/19 that was monitored by staff weekly. Resident #37 did not have a pressure ulcer to her buttocks or coccyx during this time frame. Observations on 07/23/19 at 1:33 P.M. and 3:46 P.M., on 07/24/19 at 7:38 A.M., at 10:06 A.M., and at 1:21 P.M. revealed Resident #37 sitting in a reclining chair in her bedroom or in the common area with no pressure reducing cushion in place. Observation and interview on 07/24/19 at 4:37 P.M., with Licensed Practical Nurse (LPN) #460, revealed Resident #37 sitting in her reclining chair in her bedroom with no pressure cushion in place. LPN #460 verified Resident #37 should have a pressure cushion in her recliner. An observation of Resident #37's coccyx was attempted on 07/25/19 at 6:54 A.M., however, Resident #37 was very confused, fearful, and suspicious of staff. When asked if an observation could be made later, Resident #37 appear agitated and more suspicious, asking to see staff member's identification badges. Resident #37 refused an observation of her coccyx. Review of a facility policy titled, Skin Care and Wound Treatment Protocol, dated January 2016, revealed preventative measures to utilize include positioning devices such as pillows, cushions, and overlays in beds and chairs as indicated to relieve pressure on bony area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 9 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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. Based on observation, staff interview, and medical record review, the facility to ensure fall interventions were in place as ordered and care planned. This affected one (#51) of two residents reviewed for falls. The facility identified six residents with orders for pressure pad alarms as fall interventions. The census was 72. Findings include: Review of Resident #51's medical record revealed an admission date of 05/10/19. Diagnoses included acute kidney failure, chronic kidney disease, heart failure, diabetes mellitus type II, chronic obstructive pulmonary disease, and major depression. Review of the most recently completed Minimum Data Set (MDS) assessment completed 06/09/19 revealed Resident #51 was severely cognitively impaired and was assessed as requiring limited assistance with bed mobility, transfers, and walking in the room and corridor. Review of a physician order dated 07/05/19 revealed Resident #51 was ordered a pressure pad alarm to the recliner and staff was to check placement and function every shift. Review of a fall care plan dated 07/05/19 revealed Resident #51 had an intervention to have a pressure pad alarm to Resident #51's reclining chair. Observation on 07/24/19 at 8:50 A.M. revealed Resident #51 sitting in his wheelchair in the therapy room receiving therapy services. Observation on 07/24/19 at approximately 10:00 A.M. revealed therapy staff members assisting Resident #51 back to his room by pushing his wheelchair. Observation on 07/24/19 at 10:05 A.M., revealed Resident #51 sitting in his reclining chair in his bedroom and was free from distress. Further observation in Resident #51's bedroom revealed Resident #51's pressure pad alarm was still applied to the wheelchair he returned to his bedroom with from therapy. Resident #51 was alone in his bedroom and not other alarming devices were on his recliner. Interview on 07/24/19 at 10:21 A.M. with Licensed Practical Nurse (LPN) #460 stated Resident #51 was not safe to be up and walking in his room by himself because he was not strong enough and was a fall risk. LPN #460 verified Resident #51 was ordered to have a pressure pad alarm to his recliner. Observation and interview on 07/24/19 at 10:25 A.M., with LPN #460, revealed Resident #51 sitting in his reclining chair with no pressure pad alarm in place. LPN #460 verified Resident #51 should have a pressure pad alarm to his chair, and verified the alarm device was still on Resident #51's wheelchair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 10 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, staff interview, and medical record review, the facility to ensure a urinary catheter was maintained in a manner to prevent contamination. This affected one (#51) of one residents reviewed for urinary catheters. The facility identified four residents with urinary catheters. The census was 72. Findings include: Review of Resident #51's medical record revealed an admission date of 05/10/19. Diagnoses included acute kidney failure, chronic kidney disease, heart failure, diabetes mellitus type II, chronic obstructive pulmonary disease, and major depression. Review of Resident #51's July 2019 medication orders revealed he was not currently prescribed an antibiotic, and review of nursing progress notes between 07/05/19 and 07/24/19 revealed Resident #51 had no recent urinary tract infections. Observation on 07/23/19 at 3:42 P.M., revealed Resident #51 sitting in his reclining chair with his eyes closed. Further observation revealed Resident #51's urinary catheter collection bad was laying flat on the floor in direct contact with the tile floor and was noted to have a small plastic garbage can laying on top of the urinary catheter collection bag. Observation on 07/24/19 at 7:38 A.M., revealed Resident #51 sitting in his reclining chair with his urinary catheter collection bag hanging from a small trash can in his room. The trash can contained soiled disposable rubber gloves, a face mask, and an empty oxygen concentrator humidification container. The bottom of urinary catheter collection back was also noted to be resting on the floor. Observation on 07/24/19 at 10:05 A.M., revealed Resident #51 sitting in his room in his recliner, after returning from the therapy room, and the urinary catheter collection bag was, again, observed hanging from the trash can and resting on the floor. Observation and interview on 07/24/19 at 10:25 A.M., with LPN #460, revealed Resident #51 sitting in his reclining chair with his urinary catheter collection bag hanging from the trash can and resting on the floor. LPN #460 verified Resident #51's urinary catheter collection bag should be hung from a clean surface and off the floor to prevent infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 11 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of facility staffing tools, nursing schedules, and and staff interview, the facility failed to ensure a registered nurse (RN) was on duty at least eight consecutive hours a day, seven days a week. This affected 72 of 72 residents residing in the facility. Findings include: Review of facility staffing tool documents dated 07/19/19, 07/20/19, and 07/21/19, revealed the facility did not have a RN on duty during the on the 7:00 A.M. to 7:30 P.M. shift or the 7:00 P.M. to 7:30 A.M. shift. Review of nurse staffing schedules provided by the facility dated 07/19/19, 07/20/19, and 07/21/19 revealed the facility did not have an RN on duty on any shift during the three days. Interview on 07/25/19 at approximately 12:30 P.M., with Director of Nursing (DON) #1 verified the facility did not have an RN on duty on any shift on 07/19/19, 07/20/19, and 07/21/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 12 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on employee personnel file review, staff interview, and review of facility policy, the facility failed to ensure state tested nurse aides (STNA) were provided with at least 12 hours of annual in-service training. This affected two (#500 and #501) nurse aide employee files reviewed. This deficient practice had the potential to affect 72 of 72 residing in the facility. The census was 72. Residents Affected - Few Findings include: 1. Review of STNA #500's personnel file revealed a hire date of 05/19/16. Further review of the employee file revealed STNA #500 had not had 12 hours of in-servicing in the last year. 2. Review of STNA #501's personnel file revealed a hire date of 03/16/17. Further review of the employee file revealed STNA #501 had not had 12 hours of in-servicing in the last year. Interview on 07/25/19 at 3:31 P.M. with Director of Human Resources #502 verified STNA #500 and STNA #501 did not have 12 hours of annual in-service training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 13 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure correct doses of medications were available for residents, and failed to administer medications per physician orders. This affected one (#44) of five residents reviewed for unnecessary medications. The facility identified 40 residents who received antidepressant medications in the facility. The census was 72. Findings include: Review of Resident #44's medical record revealed an admission date of 10/11/16. Diagnoses included unspecified dementia without behavioral disturbances, unspecified psychosis, chronic kidney disease, major depression, anxiety, and diabetes mellitus type II. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] MDS revealed Resident #44 had short term and long term memory problems, and severely impaired cognitive skills for daily decision making. Resident #44 was assessed with no behaviors in the look-back period of the assessment. Review of a physician order dated 07/10/19 revealed Resident #44 was ordered the antidepressant Remeron 30 milligrams (mg) by mouth every night at bedtime for depression. Review of a medication administration record (MAR) from July 2019 revealed facility nurses were documenting Resident #44 received Remeron 30 mg by mouth at bedtime between 07/10/19 through 07/23/19. Observation on 07/24/19 at 2:00 P.M., with Licensed Practical Nurse (LPN) #460, revealed Resident #44's medications in the medication cart from the facility pharmacy. Further observation inside the medication cart revealed a plastic pre-packaged pouch with Resident #44's name and printing on the outside of the pouch indicated the contents inside was a Remeron 7.5 mg tablet. Observation of the inside contents of the package revealed one Remeron 7.5 mg tablet which was to be administered on 07/24/19 at bedtime. Interview on 07/24/19 at 2:10 P.M. with LPN #460 verified Resident #44 should be receiving Remeron 30 mg by mouth at bedtime and only had 7.5 mg available. Interview on 07/24/19 at 2;15 P.M. with Director of Nursing (DON) #1 stated there was confusion with Resident #44's previous Remeron order, and after a conversation with the physician and the pharmacy, the order was corrected on 07/10/19 for Resident #44 to receive Remeron 30 mg by mouth at bedtime everyday. DON #1 stated the facility pharmacy kept sending Remeron 7.5 mg tablets that facility nurses were administering to Resident #44 at bedtime. DON #1 verified Resident #44 was not receiving her correct dose of Remeron since 07/10/19. DON #1 stated the facility had been having issues with the facility pharmacy and were actively seeking a new pharmacy to supply medications for facility residents. Observations on 07/23/19 at 2:06 P.M. and 3:48 P.M., on 07/24/19 at 7:32 A.M., at 8:52 A.M., at 10:07 A.M., and at 1:23 P.M., and on 07/25/19 at 7:21 A.M., revealed Resident #44 did not display any signs of increased depression or any acute changes to her physical or mental condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 14 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a hospice note dated 07/18/19 revealed no documentation of Resident #44 displaying any changes in mood or worsening depression. Review of a facility policy titled, Automated Dispensing Unit for Routine Medication Administration, dated December 2017, revealed the facility may use an automated dispensing unit (ADU) for routine administration, where permitted by regulation or law. ADUs may be used by authorized facility staff and contents are property of the pharmacy. New medication orders received by the nurse are transmitted to the pharmacist, and after review and authorization of the order, the medication is made available for the ADU to dispense when needed next. The nurse then accesses the medications for the time needed and initiates the dispensing of all authorized medications by the dispensing unit. When the packaging process is complete, the nurse checks the packaged drugs, secures the room, and stores any medications not needed immediately in the medication cart. Review of a facility policy titled, Medication Administration, revised May 2019, revealed prescribed medications are ordered and delivered in a timely fashion to residents. The five rights (resident, drug, dose, route, and time) to medication delivery will be followed for all medication passes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 15 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure monthly pharmacy review irregularities were reviewed by the physician. This affected one (#25) of five residents reviewed for unnecessary medications. The facility census was 72. Findings include: Review of Resident #25's medical record revealed an admission date of 06/30/17. Medical diagnoses included Parkinson's disease, dementia with behaviors, hypertension, anxiety disorder, major depressive disorder, syncope and collapse, dysphagia, and generalized weakness. Review of the resident's Minimum Data Set assessment dated [DATE] revealed no impairment in cognition. The resident received antipsychotic, antianxiety, antidepressant, and opioid medication. Review of the resident's monthly pharmacy reviews revealed recommendations were made to the physician in July 2018, December 2018, January 2019, and February 2019. Further review of the resident's medical record revealed no indication what the recommendations were or that the physician had ever responded to the recommendations. Interview with the Director of Nursing on 07/24/19 at 10:03 A.M., verified the pharmacist made recommendations in July 2018, December 2018, January 2019, and February 2019 and the facility had no record of what the recommendations were. She stated she spoke with the pharmacist and he was not able to provide them to the facility. She verified there was no documentation from the physician indicating a response to the pharmacy recommendations. Review of a facility policy titled Medication Regimen Review dated 12/17 revealed resident medication irregularities are documented in the resident's active record and reported to the Director of Nursing, attending physician, and the medical director. Recommendations are acted upon and documented on by the facility staff and/or the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 16 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's as needed (PRN) antianxiety medication was time limited. This affected one (#25) of five residents reviewed for unnecessary medications. The facility identified 14 residents on antianxiety medications. The facility census was 72. Findings include: Review of Resident #25's medical record revealed an admission date of 06/30/17. Medical diagnoses included Parkinson's disease, dementia with behaviors, hypertension, anxiety disorder, major depressive disorder, syncope and collapse, dysphagia, and generalized weakness. Review of the resident's Minimum Data Set assessment dated [DATE] revealed no impairment in cognition. The resident received antianxiety medication. Review of the resident's physician's orders revealed an order dated 11/13/18 for Ativan (antianxiety medication) 0.5 milligrams (mg) twice daily as needed (PRN) for anxiety. Review of the resident's Medication Administration Record revealed she received the Ativan one time in June and three times in July. Interview with Regional Clinical Director #210 on 07/25/19 at 2:20 P.M. verified the resident had a PRN Ativan order since 11/13/18. She verified there was no stop date and no rationale for extending its use. Review of a facility policy titled Antipsychotic/Psychotropic Medication and GDRs revised on 01/19 revealed PRN psychotropic drug orders are limited to 14 days. The attending physician/nurse practitioner, if appropriate may extend the PRN order beyond 14 days; but should document their rationale in the resident's medical record and indicate the duration for the PRN order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 17 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of facility policies, the facility failed to ensure the ice machine was maintained in a sanitary manner. This had the potential to affect all residents except two (Residents #10 and #56) who the facility identified as not receiving any food by mouth (NPO). The facility census was 72. Findings include: Observation of the facility kitchen on 07/22/19 at 9:13 A.M., revealed the bin type ice machine contained a layer of black colored debris, which appeared to be mold, across the inside top of the ice machine. The interior sides of the ice machine contained a grayish-white lime-like substance. Interview and observation with Dietary Manager #220 at the time of the above observation verified these findings. She stated the maintenance department was responsible for sanitizing the ice machine. She was unable to state when the ice machine had been cleaned last. She stated it should be cleaned twice weekly. Further interview with Dietary Manager #220 on 07/24/19 at 11:54 A.M., verified the facility had no documentation indicating the ice machine had ever been deep cleaned. She stated they had called an outside company to schedule this service. Review of a facility policy titled Production, Storage, and Dispensing of Ice revised on 01/01/19 revealed ice will be produced, stored and dispensed in a manner to avoid contamination. The ice dispenser will be cleaned and sanitized. Inside and outside of machine and the area around the machine will be cleaned. Review of a facility policy titled Cleaning Instructions: Ice Machine and Equipment revised 01/01/19 revealed ice machine and equipment will be cleaned and sanitized on a regular basis. Procedures included unplug the ice machine and remove the ice. Wash the interior thoroughly using a detergent solution. Rinse and drain the interior with clean hot tap water. Sanitize. Air dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 18 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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. Based on facility assessment review and staff interview, the facility failed to include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet the residents' needs. This deficient practice had potential to affect 72 of 72 residents residing in the facility. The census was 72. Findings include: Review of the facility assessment from 2019 revealed no documentation of the facility evaluating the staff needed to ensure sufficient number of qualified staff are available to meet each resident's need. The assessment failed to include the knowledge and skills required of staff to maintain the highest resident well-being and current professional standards of practice based on a competency-based approach, and did not address individual staff assignments and systems for coordination and continuity of care. Interview on 07/25/19 at 2:34 P.M. with Administrator #2 verified the facility assessment did not include an evaluation of facility staffing needs and staffing knowledge and skills. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 19 of 20 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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 review of the facility's Legionella and waterborne illness prevention documentation and staff interview, the facility failed to implement a legionella control plan with identified control measures and documentation. This had the ability to affect 72 of 72 residents residing in the facility. The census was 72. Residents Affected - Many Findings include: Review of a facility policy titled Legionella dated [DATE] revealed the facility would proactively maintain water systems within the facility against the bacterium Legionella and other water-borne pathogens. The facility would specify protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Further review of the facility Legionella risk management documentation revealed no flow sheet indicating potential risk areas in the facility. The facility indicated their water temperatures were normally above or below the temperature Legionella grows best (77 to 108 degrees) and stated temperature checks were periodically taken to verify temperature. The risk management documentation also indicated Legionella growth may be affected by water laying dormant in lines and changing temperature due to low census and short term shutdown of resident room wings or corridors. Any time a wing is unoccupied and then readied for reoccupation, special care will be given to the hot and cold water systems in the affected rooms, including flushing lines and monitoring water temperatures prior to reoccupancy. Interview with Maintenance Director #200 on [DATE] at 3:32 P.M. verified the facility did not have a flowsheet indicating what areas of concern should be monitored. He verified the facility had not implemented control measures to monitor for legionella and other waterborne illnesses other than the monitoring of temperatures in resident rooms for temperatures within the required 105-120 degrees. He stated the facility did not have a water management team established. He verified the facility had rooms that were not in use and eyewash stations and an ice machine that could be potential risk areas. He had no documentation of control measures for these areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366162 If continuation sheet Page 20 of 20