Health inspection·April 22, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interview, and facility policy review the facility failed to notify the family of a residents change of condition and transfer to local hospital for evaluation and treatment of stroke symptoms. This affected one resident (#44) reviewed for notification of change of condition. The facility census was 48. Findings include: Review of the medical record for Resident #44 revealed a re-admission date of 01/23/24 with a diagnosis of cerebral infarct (stroke). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of the facility form titled HIPAA/PHI Authorization and Consent Form dated 12/23/23 from admission revealed Resident #44 identified his brother as his emergency contact. Review of the nursing progress noted dated 01/13/24 at 3:23 P.M. for Resident #44 revealed the nurse was called to the resident's room and was noted to have right sided facial droop. Resident #44 complained of feeling right sided numbness and tingling. Resident #44 was able to move his right hand some and able to squeeze with both hands. Vital signs for Resident #44 revealed a blood pressure of 171/95 millimeters of mercury (mm/Hg), a pulse of 90 beats per minute, a respiratory rate of 18 breaths per minute, and his oxygen saturation was 95%. The nurse called on-call physician for Resident #44's primary physician and left a message. The nurse then called the emergency number 911 on 01/13/24 at 9:00 A.M. two Emergency Medical Services (EMS) personnel arrived, and Resident #44 was transported to the nearest hospital for evaluation and treatment. Review of the nursing progress notes revealed no documentation of notification of the family or representative for Resident #44 following discharge from the facility for a change in medical condition. Interview on 04/22/24 at 2:15 P.M. with a family member of Resident #44 revealed the facility did not contact any family member regarding the transfer to the hospital for a change of condition. Interview on 04/22/24 at 3:40 P.M. with the Director of Nursing (DON) verified the family for Resident #44 was not notified of change of condition or transfer to hospital for stroke symptoms. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366162 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 04/22/2024 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)