Inspection·August 1, 2019

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 record review and interview the facility failed to maintain complete resident care plans. This affected three (Residents #27, #34, and #40) of 18 residents reviewed for complete plans of care. The census was 45. Findings Include: 1. Review of medical record for Resident #27 revealed a diagnosis of unspecified psychosis dated 07/11/19. Review of physician orders revealed the resident is receiving Risperdal (antipsychotic) dated 03/09/19, and Depakote (antiseizure) dated 01/12/19, used for certain psychiatric disorders. Review of plan of care dated 01/25/19 revealed no plan of care or interventions for psychosis or seizures. 2. Review of medical record for Resident #34 revealed diagnoses including acute respiratory failure, cerebral infarction, unspecified, chronic kidney disease, and deep tissue wounds to right foot. Review of physician orders revealed the resident is receiving acetaminophen 500 milligrams dated 06/15/16, morphine 20 milligrams, and tramadol 50 milligrams for pain. Review of plan of care dated 04/18/19 revealed no plan of care created for the treatment and control of pain. Interview on 08/01/19 at 11:30 A.M., the Director of Nursing (DON) verified that Residents #27 and #34 plans of care lacked documentation related to treating psychosis and pain. 3. Review of the medical record for Resident #40 revealed the resident was admitted on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, altered mental status and major depressive disorder. Review of the physician's orders revealed Resident #40 is receiving Seroquel (antipsychotic) dated 09/06/18 and Zoloft (antidepressant) dated 09/06/18, used for certain psychiatric disorders. Review of the plan of care dated 07/15/19 revealed no plan of care created for the treatment and care of depression and psychosis. (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 4 Event ID: 366280 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 366280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Luke Lutheran Community-Portage Lakes 615 Latham LN Akron, OH 44319 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)