Inspection·June 27, 2022

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 record review and staff interview, the facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 30 residents currently residing in the facility. Findings include: On 06/22/22 from 10:30 A.M. to 11:30 A.M., facility staffing tool was completed with Scheduler #900. Scheduler #900 stated that four different agencies were utilized to staff the facility. Review of all timecards for facility staff and agency staff for 05/26/22 through 06/01/22, revealed that on 05/26/22 the Interim Director of Nursing (IDON) worked in the facility 3.75 hours. Scheduler #900 verified the IDON was agency contracted and confirmed the timecard at the time of the finding. Further review of agency timecards for 05/26/22 through 06/01/22, revealed Registered Nurse (RN) #902 worked in the facility on 05/30/22 for 7.0 hours. This was verified by Scheduler #900 at the time of the finding. Phone interview on 06/24/22 at 5:17 P.M. with the Administrator revealed an email was sent regarding registered nurse coverage on 05/26/22 and 05/30/22. The Administrator stated RN #901 had worked at the facility doing Minimum Data Set (MDS) assessments on 05/26/22 for two hours and was reviewing orders for MDS on 05/30/22 for four and half hours. RN #901 was not on the staff identification list that was provided by the facility. The Administrator stated that RN #901 was from the sister facility. A request was made for electronic documentation that RN #901 was physically in the facility, and no documented evidence was received. This deficiency substantiates Master Complaint Number OH00133308 and Complaint Numbers OH00133030 and OH00132348. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366280 If continuation sheet Page 2 of 5 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 06/27/2022 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the pharmacy recommendations were addressed by the physician in a timely manner. This affected two residents (Resident's #4 and #13) of five residents reviewed for unnecessary medications. The facility census was 30. Residents Affected - Few Findings include: 1. Review of Resident #4's medical record revealed an admission date of 12/27/19 with diagnoses including dementia with behavioral disturbances, major depressive disorder, and COVID-19. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had impaired cognition and required extensive assistance for activities of daily living. Resident #4 received antidepressant medication daily over the seven-day look back period. Review of the pharmacy recommendation dated 03/01/22 revealed Pharmacist #827 recommended options to reduce antiplatelet medication. Resident #4 was currently on 81 milligrams (mg) aspirin once a day and clopidogrel (blood thinner) 75 mg given daily in the A.M. Pharmacist #827 recommended either to discontinue the aspirin or clopidogrel related to geriatric syndromes increase the risk for both thrombotic and bleeding events. Pharmacist #827 recommended that if physician would continue both antiplatelets, that reasoning should be provided. On 06/22/22 Physician #828 responded to the recommendation by requesting more investigation with daughter, cardiologist, and neurologist. Review of the pharmacy recommendation dated 06/01/22 revealed that Pharmacist #827 recommended a gradual dose reduction consideration for Resident #4, who received 250 mg divalproex (medication to treat epilepsy and manic-depressive disorder) at bedtime, 25 mg quetiapine (antipsychotic) and 20 mg duloxetine (antidepressant). Physician #828 responded with no rationale and checked the box to continue use is in accordance with standards of practice. Interview on 06/23/22 at 8:59 A.M. with Interim Director of Nursing (IDON) #833 verified the above findings. 2. Review of Resident #13's medical record revealed an admission date of 10/14/21 with diagnoses including Alzheimer's disease, major depressive disorder, anxiety disorder, and chronic kidney disease. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #13 had impaired cognition and required extensive assistance for most activities of daily living. Resident #4 received antipsychotic and antidepressant medications daily during the seven-day look back period. Review of the pharmacy recommendation dated 03/01/22 revealed Pharmacist #827 recommended a gradual dose reduction consideration for Resident #13, who received 25 mg quetiapine (antipsychotic) in the A.M. and 50 mg in the P.M. and 30 mg once a day citalopram (antidepressant). Pharmacist #827 indicated the maximum recommended dose for citalopram in the elderly is 20 mg per day. On 06/22/22 Physician #828 responded with no rationale and checked the box to continue use is in accordance with standards of practice. Review of the pharmacy recommendation dated 06/01/22 revealed Pharmacist #827 recommended a gradual dose reduction consideration for Resident #13, who received 25 mg quetiapine in the A.M. and 50 mg in the P.M. and 30 mg once a day citalopram. Pharmacist #827 indicated the maximum recommended dose for citalopram in the elderly is 20 mg per day. On 06/22/22 Physician #828 responded with no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366280 If continuation sheet Page 3 of 5 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 06/27/2022 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)

F 0757 rationale and checked the box to continue use is in accordance with standards of practice. Level of Harm - Minimal harm or potential for actual harm Interview on 06/23/22 at 8:59 A.M. with IDON #833 verified the above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366280 If continuation sheet Page 4 of 5 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 06/27/2022 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)

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 facility policy, the facility failed to ensure kitchen food storage and handling was maintained in a safe and sanitary manner. This had the potential to affect 29 of 30 residents receiving food from the kitchen. Resident #12 received no food from the kitchen. The facility census was 30. Findings include: A kitchen tour was conducted on 06/21/22 between 8:25 A.M. and 9:20 A.M. with the Dietary Chef Manager (DCM) #831. Observation of the following packaged foods stored in the kitchen refrigerator were noted to be expired, without a dated label and/or open to the air: mozzarella cheese, American cheese, two jars of beef base, pickle relish, and a head of lettuce. DCM #831 verified the packaged foods listed above was not labeled and/or left open to the air at the time of observation. Observation of the kitchen freezer on 06/21/22 at 8:40 A.M. with DCM #831, revealed the following packaged foods were noted to be expired, without a dated label and/or open to the air: two packages of chicken fingers, blueberry muffins, cranberry muffins, green beans, four packages of hot dogs, onion rings; loaf of multigrain bread; tater tots; two packages chicken breast, frozen diced potatoes, and chicken strips. DCM #831 verified the packaged foods listed above were not labeled and/or left open to the air at the time of observation. Observation of kitchen walk-in refrigerator on 06/21/22 at 8:50 A.M. with DCM #831, revealed the following packaged foods were noted to be expired, without a dated label and/or open to the air: macaroni salad, minestrone soup, beef Orzo soup, and a carton of whipping cream. DCM #831 verified the packaged foods listed above were not labeled and/or left open to the air at the time of observation. Observation on 06/21/22 at 11:08 A.M. revealed Administrative Assistant (AA) #799 entered the kitchen area through a side door without a hairnet or washing her hands and proceeded to scoop ice from the kitchen ice bin. AA #799 walked past the sink and a posted sign that stated masks and hairnets are to be always worn in the kitchen and hallway. Interview on 06/21/22 at 11:10 A.M. with General Food Manager (GFM) #829, verified AA #799 entered the kitchen food preparation area without a hairnet and without washing her hands prior to handling kitchen equipment. Interview on 06/21/22 at 11:00 A.M. with Regional Director of Operations for the food service management company (RDO) #826 confirmed stored food items were to be sealed airtight and labeled with the opened date and the expiration date. Review of Resident Dining and Meal Summary, dated 06/22/22, revealed 30 residents received food from the kitchen and one resident (Resident #12) was ordered NPO (nothing by way of mouth). Review of the undated policy titled, Morrison Orange Food labels, stated every item prepped, prepared, or opened, must have a label with every line filled out. Further review revealed all labels must have the name of the product, the date prepared or opened, expiration date, and initial of person completing the label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366280 If continuation sheet Page 5 of 5