Inspection·May 23, 2023

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nurse's note dated 03/08/23 at 1:18 P.M. revealed the nurse spoke with the social worker from hospice and asked her to ask the hospice nurse for an air mattress order due to Resident #29's left trochanter wound and the hospice social worker stated she would speak to the nurse and get it ordered for the facility. Review of the physician's orders dated 03/11/23 revealed Resident #29 had an order to apply skin prep and a silicone foam dressing to the left ischium every third day and as needed for skin integrity. Review of the nurse's note dated 03/13/23 at 2:45 P.M. revealed the nurse asked the hospice nurse on 3/10/23 for an air mattress for the resident and the hospice nurse stated to this nurse that hospice would not cover the cost of an air mattress, the resident did not meet the qualifications, and the resident had a gel overlay mattress. The Director of Nursing (DON) was notified. Review of the nurse's note dated 03/13/23 at 4:08 P.M. revealed the nurse called hospice and requested an air mattress for Resident #29. They stated they would have one delivered the next day. Review of the physician's orders dated 03/16/23 revealed Resident #29 had an order for an air mattress to the bed. Review of the physician's orders dated 03/27/23 revealed Resident #29 had an order to cleanse the sacrum, left buttock cheek and left hip with normal saline, apply calcium alginate with silver and Medi-honey, and cover with border foam dressing every day and as needed. Review of the physician's order dated 05/03/23 revealed Resident #29 had orders to cleanse the sacrum, left buttock cheek and left hip with normal saline, apply calcium alginate and Medi-honey, skin prep to the peri-wound and cover with border foam dressing every day and as needed and to cleanse the right foot planter with normal saline, apply collagen with silver and Medi honey, cover with abdominal dressing and wrap with kerlix every day and as needed. Review of the Treatment Administration Record (TAR), dated May 2023, revealed the orders dated 05/03/23 for treatments to the sacrum, left buttock cheek, left hip and right foot coincided with the physician orders dated 05/03/23. All of these orders were documented as being completed from 05/03/23 through 05/17/23 on the TAR. Observation on 05/18/23 at 1:15 P.M. with Hospice Aide (HA) #100 who was providing care to Resident #29 revealed Resident #29 had a dressing to her left hip, left buttock and right foot all dated 05/15/23. The dressing to the coccyx was not visible due to Resident #29 wearing a brief. Observation and record review on 05/18/23 at 1:20 P.M. with Agency Registered Nurse (ARN) #101 revealed Resident #29 had an order for her wound dressings to be changed daily and as needed. ARN #101 verified at this time the dressing to her left buttock, left hip and right foot were dated 05/15/23 and the dressing to the coccyx did not have a date on it as to when it had last been changed. On 05/18/23 at 2:05 P.M. an interview with Licensed Practical Nurse (LPN) #102 revealed she completed wound rounds with the Wound Nurse Practitioner (NP) every Thursday, however, Resident #29 was on hospice, so the wound NP would not see her. LPN #102 stated Resident #29's wound treatments had been ordered every three days, but the orders changed to daily on 05/03/23 per the daughter's request. LPN #102 stated there must have been a miscommunication because Resident #29's wound treatments were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366280 If continuation sheet Page 2 of 3 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 05/23/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not getting done daily. LPN #102 stated she was trying to get to all residents with wounds, but she was only one person and the facility only had two staff nurses and the rest were agencies. LPN #102 verified the nurses should have seen that the order in the computer was changed to daily dressing changes and completed Resident #29's treatments daily. On 05/22/23 at 11:45 A.M. an interview with LPN #102 revealed she had asked the hospice for an air mattress, and it took them a week to give the facility an order for it. On 05/22/23 at 1:15 P.M. an interview with Family Member #801 revealed she had visited the facility on 05/02/23 and had concerns related to the resident's wound care. The family member indicated her mother's (Resident #29) room had a foul odor when she walked into the room and the wound dressings were dated 04/25/23. This deficiency represents non-compliance investigated under Complaint Number OH00142643. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366280 If continuation sheet Page 3 of 3