Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record review, interview and facility policy review, the facility failed to ensure physician orders
and comprehensive assessments were completed prior to the implementation of physical restraints. This
affected two residents (Resident #2 and #9) of three residents reviewed for restraints. The census was 31.
Residents Affected - Few
Findings included:
Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses
included dementia with behavioral disturbance, cerebral infarction, diabetes, anxiety disorder, vascular
dementia, seizures, drug induced dyskinesia, impulse disorder, insomnia, abnormal posture, and lack of
coordination.
Review of the plan of care dated 01/23/23 revealed Resident #2 was at risk for falls due to balance issues,
antidepressant medication use, no recent falls, was transferred with a Hoyer (brand of mechanical sling lift).
Interventions included self-releasing seatbelt in the wheelchair.
Review of the Modification to the quarterly Minimum Data Set assessment dated [DATE] revealed Resident
#2 had severely impaired cognition, no behaviors and no trunk or chair restraint.
Review of the physician's orders revealed Resident #2 had an order for a self-releasing seatbelt to the tilt
and space wheelchair to keep resident in the proper position to propel self in the wheelchair dated
09/25/23.
Further review of the medical record revealed no restraint assessment was completed prior to the
implementation of the self-release seatbelt in the wheelchair.
Review of the Physical Restraint and Elimination assessment dated [DATE] revealed Resident #2 was
non-ambulatory/wheelchair mobile with assist, non-weight bearing, slides down when sitting, required total
assist of one staff for activities of daily living (ADLs), had a history of falls, was forgetful, was taking
antipsychotic and antidepressants (medications). She received a total score of 22 per the assessment,
indicating she had a good candidate status for a restraint elimination program however further
documentation on the assessment revealed the resident was not a candidate for a restraint reduction or
elimination program and the action plan was to continue with the self-releasing seat belt to the wheelchair
due to a history of falls.
Observation on 10/18/23 at 9:10 A.M. revealed Resident #2 had a seatbelt buckled over her hips in
(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 11
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
10/25/2023
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 0604
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
her tilt in space wheelchair. Agency State Tested Nursing Assistant #200 asked Resident #2 to release her
seatbelt buckle several times and she was unable to release the buckle herself. STNA #200 verified the
resident was unable to unbuckle the seatbelt.
On 10/18/23 at 9:15 A.M. an interview with Licensed Practical Nurse (LPN) #101 revealed Resident #2 had
dyskinesia (abnormal, involuntary movements) and jerking movement, She stated the seatbelt was to
prevent her from falling out of the wheelchair and her responsible party was insistent she have the seat belt
on.
Observation on 10/18/23 at 12:00 P.M. revealed Resident #2 was in the dining room eating lunch with her
seatbelt on and buckled.
Observation on 10/18/23 at 5:00 P.M. revealed Resident #2 was in the dining room eating dinner with her
seatbelt on and buckled.
On 10/19/23 at 9:00 A.M. an interview with the Director of Nursing verified there was not proper
assessment or documentation to indicate the need for a seatbelt for Resident #2 to determine if it was a
restraint.
On 10/23/23 at 2:26 P.M. an interview with the Administrator revealed Resident #2 could release her
seatbelt herself. An observation at this time with the Administrator revealed Resident #2 was unable to
release her seatbelt herself. She would grab it and try to pull it apart and then she would grab her lift pad
and pull on it. He stated she was able to do it two months ago when the physician asked to see her release
it.
2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses
included intellectual disabilities, intracranial injury, epilepsy, hemiplegia affecting the left side, abnormal
involuntary movements, and abnormal posture.
Review of the plan of care dated 12/20/04 revealed Resident #9 was at risk for falls related to needing
assistance in ADLs and mobility, inability to maintain positioning on own, unable to effectively communicate
needs, seizure disorder, generalized muscle weakness, spastic hemiplegia affecting both sides, intellectual
disabilities, and history of falls. Interventions included for staff to not leave Resident #9 unattended without
her seatbelt or tray on.
Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #9 had severely
impaired cognition and had no trunk or chair restraint.
Further review of the medical record revealed Resident #9 did not have a physician's order or a restraint
assessment completed for a self-releasing seatbelt.
Observation on 10/18/23 at 11:10 A.M. with LPN #101 revealed Resident #9 could not remove her
self-releasing seatbelt. She verified the resident could not remove it herself.
On 10/19/23 at 9:00 A.M. an interview with the Director of Nursing verified Resident #9 did not have a
restraint assessment completed for the use of the self-release seatbelt.
On 10/23/23 at 1:36 P.M. an interview with the Director of Nursing verified Resident #9 did not have an
order for the self-releasing seatbelt in the tilt in space wheelchair.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 2 of 11
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
10/25/2023
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 0604
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the undated facility policy titled, Restraint Free Environment, revealed the was the facility policy
each resident should attain the maintain their highest practicable well-being in an environment that prohibits
the use of restraints for discipline or convenience and limits restraint use to circumstances in which the
resident had medical symptoms that warrant the use of medical restraints.
A physical restraint referred to any manual method or physician or mechanical device, material, or
equipment attached or adjacent to the resident's body that the individual cannot remove easily which
restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not
limited to: using devices in conjunction with a chair such as trays, tables, cushions, bars or belts, that the
resident cannot remove and prevents the resident from rising. Falls do not constitute self-injurious behavior
or a medical symptom that warrants the use of a physician restraint. A physician's order alone was not
sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the
determination to use the restraint. Before a resident is restrained, the facility will determine the presence of
a specific medical symptom that would require the use of restraints and determine how the use of restraints
would treat the medical symptoms;
This deficiency represents non-compliance investigated under Complaint Number OH00146827.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 3 of 11
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
10/25/2023
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
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, record review, manufacturer guideline review, policy review and interview the facility failed to
ensure comprehensive wound management was provided per orders and care plan. This affected one
resident (Resident #18) of three residents reviewed for pressure ulcers. The census was 31.
Residents Affected - Few
Findings included:
Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses
included abnormal posture, severe protein-calorie malnutrition, cerebral palsy, and epilepsy. The resident
was discharged to the hospital on [DATE] and re-admitted to the facility on [DATE].
Review of the Discharge Minimum Data Set assessment dated [DATE] revealed Resident #18 had
moderately impaired cognition and no unhealed pressure injures.
Review of the nurse's note dated 09/24/23 at 12:18 A.M. revealed Resident #18 had a Stage II pressure
ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed,
without slough (yellow or white substance in a wound) or bruising) to his left ankle upon re-admission to the
facility.
Review the wound assessment dated [DATE] revealed Resident #18 had a Stage II pressure ulcer to the
left inner ankle which measured 0.5 centimeters (cm) in length by 0.7 cm in width by 0.1 cm in depth. There
was scant amount of serosanguineous (clear, blood tinged) drainage.
Review of the care plan dated 09/25/23 revealed the resident returned from the hospital with a pressure
injury to the left ankle with interventions including air mattress, consult the wound nurse practitioner,
encourage turning and repositioning, measure (the wound) weekly, treatment provided per physician
orders,
Review the wound assessment dated [DATE] revealed Resident #18 had a suspected deep tissue injury
(SDTI) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of
underlying soft tissue from pressure and/or shear) to the left inner ankle which measured 1.5 cm in length
by 2.0 cm in width by 0.0 cm in depth. There was no drainage.
Review of the Wound Nurse Practitioner (WNP) note dated 09/28/23 revealed Resident #18 had a SDTI to
his left medial ankle measuring 1.5 cm by 2.0 cm by 0.0 cm. The wound was intact, non-blanchable, dark
purple/maroon in color.
Review of the physician's orders revealed Resident #18 had an order to cleanse the left ankle with normal
saline, apply skin prep, cover with an abdominal dressing, and wrap with kerlix (gauze) three times a week
and as needed on Tuesday, Thursday and Sunday. The order was dated 09/28/23.
Review the wound assessment dated [DATE] revealed Resident #18 had a Stage II pressure ulcer to the
left inner ankle which measured 0.5 cm in length by 0.5 cm in width by 0.1 cm in depth. There was no
drainage.
Review the wound assessment dated [DATE] revealed Resident #18 had a SDTI to the left inner ankle
which measured 1.0 cm in length by 1.0 cm in width by 0.0 cm in depth. There was no drainage.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 4 of 11
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
10/25/2023
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
Review the wound assessment dated [DATE] revealed Resident #18 had a SDTI to the left inner ankle
measuring 2.5 cm in length by 4.0 cm in width by 0.0 cm in depth. There was no drainage. Further review
revealed both areas to the left ankle were now measured as one total area.
Review of the WNP note dated 10/16/23 revealed the SDTI to the left medial ankle of Resident #18
measured 2.5 cm by 4.0 cm by 0.0 cm.
Review of the October 2023 treatment administration record revealed no documentation of the treatment to
the resident's left ankle as ordered on 10/01/23, 10/12/23, 10/15/23, and 10/19/23.
Observation of wound care on 10/23/23 at 10:37 A.M. with Licensed Practical Nurse (LPN) # 102 and
Registered Nurse #103 revealed Resident #18 was on an air mattress. The dressing to his left ankle was
dated 10/20/23 and was initialed by LPN #102. The air mattress on the resident's bed was set at 260
pounds (setting for a resident weighing 260 pounds). LPN #102 verified the resident did not weigh that
much (the resident weighed 153 pounds on 10/01/23). His wound measured 3.0 cm by 2.5 cm by 0.0
centimeters. There were two separate wounds however the nurse measured them together as one wound.
Both wounds were approximately the size of a dime with the top wound having a small yellow center with
the rest of the wound bed with pink tissue, and dry peeling edges and the lower wound had two small
scabbed areas in the wound bed with the remaining wound bed pink with peeling edges. LPN #102 stated
she was measuring them as one single wound because the WNP was measuring the wounds as one area.
On 10/23/23 at 11:10 A.M. interview with LPN #102 verified the resident's dressing was dated 10/20/23 and
had had not been changed on 10/22/23 despite documentation on the TAR indicating the dressing had
been changed on 10/22/23. LPN #102 verified there was no documentation his dressing had been changed
on 10/01/23, 10/12/23, 10/15/23, and 10/19/23.
Review of the un-dated Wound Treatment Management Policy revealed it was the policy of the facility to
provide evidence-based treatments in accordance with current standards of practice and physician orders.
Treatments will be documented on the Treatment Administration Record (TAR) or in the electronic health
record.
Review of the manufacturer's guidelines for the air alternating pressure mattress revealed to adjust the
weight (setting) according to each individual.
This deficiency represents non-compliance investigated under Complaint Number OH00146827.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 5 of 11
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
10/25/2023
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 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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, interview, facility policy review and product safety data sheet review the facility
failed to ensure hazardous chemicals were properly stored and failed to ensure fall interventions were in
place for Resident #2.
This had the potential to affect five residents (Resident #2, #6, #14, #15, and #24) identified with impaired
cognition and independent mobility and one resident (Resident #2) of three residents reviewed for falls. The
facility census was 31.
Findings included:
1. Observation on 10/18/23 at 11:45 A.M. revealed a bottle of toilet bowl cleaner was located on the floor,
outside of room [ROOM NUMBER]. No staff were observed.
On 10/18/23 at 11:58 A.M. an interview with Registered Nurse #100 verified the toilet bowl cleaner should
not be in the hallway unattended.
The facility identified Resident #2, #6, #14, #15, and #24 with impaired cognition and independent with
mobility.
Review of the undated facility policy titled, Environmental Services Safety Procedures, revealed staff would
ensure equipment and chemical were properly stored and not left unattended in areas that were accessible
to residents.
Review of the Product Safety Data Sheet for Clinging Toilet Bowl Cleaner dated 07/12/19, revealed the
chemical causes severe skin burns, serious eye damage and burns/serious damage to the mouth throat
and stomach if ingested.
2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses
included dementia with behavioral disturbance, cerebral infarction, diabetes, anxiety disorder, vascular
dementia, seizures, drug induced dyskinesia (involuntary, abnormal movements), impulse disorder,
insomnia, abnormal posture, and lack of coordination.
Review of the Modification to the quarterly Minimum Data Set assessment dated [DATE] revealed Resident
#2 had severely impaired cognition, no behaviors and no trunk or chair restraint.
Review of the plan of car dated 02/21/22 revealed Resident #2 had a potential for falls due to she required
assist with mobility needs and received medication that increased her risk. Interventions included to place
Dysem (a pliable, anti-slid material) on top of and under the cushion in the wheelchair to prevent sliding
dated 09/24/21.
Observation on 10/19/23 at 10:30 AM revealed Resident #2 did not have any Dysem to her wheelchair.
State Tested Nursing Assistant (STNA) #201 verified at this time she did not have any Dysem in her
wheelchair or between her lift pad and the wheelchair. She stated midnight shift assisted the resident into
her chair but she did not believe the resident was to get the Dysem anymore.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 6 of 11
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
10/25/2023
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 0689
Level of Harm - Minimal harm
or potential for actual harm
On 10/23/23 at 9:25 A.M. an interview with the Director of Nursing revealed Resident #2 was to have
Dysem in her wheelchair when she was in the wheelchair as a fall intervention.
This deficiency represents non-compliance investigated under Complaint Number OH00146827.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 7 of 11
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
10/25/2023
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 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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, interview and policy review the facility failed to provide timely
incontinence care. This affected one resident ( Resident #2) of three residents reviewed for incontinence.
The census was 31.
Findings included:
Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses
included dementia with behavioral disturbance, cerebral infarction, diabetes, anxiety disorder, vascular
dementia, seizures, drug induced dyskinesia (uncontrolled movements), impulse disorder, insomnia,
abnormal posture, and lack of coordination.
Review of the plan of care dated 01/23/23 revealed Resident #2 needed assistance due to incontinence
noted and multiple medical conditions. Staff to help with proper change and assist with clothing
adjustments. Interventions included check for wetness before meals, after meals, at bedtime and on rounds
during the night.
Review of the Modification to the quarterly Minimum Data Set assessment dated [DATE] revealed Resident
#2 had severely impaired cognition and was incontinent of bowel and bladder.
Observation of incontinence care on 10/19/23 at 10:30 AM revealed State Tested Nursing Assistant (STNA)
#201 and STNA #202 provide incontinence care for Resident #2. Resident #2 had a strong urine odor and
was incontinent of a large amount of urine in her brief. STNA #201 verified the resident was wet, had a
strong urine odor, and the STNA stated the midnight shift had assisted the resident into her wheelchair
around 6:00 A.M. and STNA #201 verified her shift began at 7:00 A.M. and this was the first time, during
her shift, that staff provided incontinence care to Resident #2.
On 10/19/23 at 10:53 A.M. an interview with the Director of Nursing verified incontinence care was to be
provided to residents with incontinence at least every two hours or as needed.
Review of the facility policy titled, Perineal Care, dated 10/04 revealed perineal care was to be provided to
clean the perineum, provide comfort, and decrease risks of infection. All residents were to receive perineal
care after each episode of incontinence by the nursing personnel who are trained to provide such care.
This deficiency represents non-compliance investigated under Complaint Number OH00146827.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 8 of 11
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
10/25/2023
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and interview the facility failed to ensure oxygen tubing was changed per
physician orders. This affected three residents (Resident #3, #6 and #11) of five residents who receive
oxygen therapy. The census was 31.
Residents Affected - Few
Findings included:
1. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses
included respiratory failure, metabolic encephalopathy, acute cough, adult failure to thrive, and heart failure.
Review of the physician's orders revealed Resident #3 had an order to change oxygen tubing and nebulizer
tubing and date every Sunday night dated 07/24/22.
Review of the October Medication administration records revealed no documentation of the oxygen tubing
being changed on 10/22/23 for Resident #3.
Observation on 10/23/23 at 9:32 A.M. with Agency Registered Nurse #103 revealed the oxygen tubing for
Resident #3 was dated 10/16/23. She verified it had not been changed the night before.
2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses
included chronic obstructive pulmonary disease, pacemaker, congestive heart failure, and acute kidney
failure.
Review of the physician's orders revealed Resident #6 had an order to change oxygen tubing and nebulizer
tubing and date every Sunday night dated 07/24/22.
Review of the October Medication administration records revealed no documentation of the oxygen tubing
being changed on 10/22/23 for Resident #6.
Observation on 10/23/23 at 9:32 A.M. with Agency Registered Nurse #103 revealed the oxygen tubing for
Resident #6 was dated 10/17/23. She verified it had not been changed the night before.
3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses
included acute respiratory failure, anxiety disorder, hypertension, hypoxemia, and asthma.
Review of the physician's orders revealed Resident #11 had an order to change oxygen tubing and
nebulizer tubing and date every Sunday night dated 07/24/22.
On 10/19/23 at 1:30 P.M. an interview with Resident #11 revealed the staff never change her oxygen tubing
like they should. She stated sometimes it will go a month without being changed.
Review of the October Medication administration records revealed no documentation of the oxygen tubing
being changed on 10/22/23 for Resident #11.
Observation on 10/23/23 at 9:32 A.M. with Agency Registered Nurse #103 revealed the oxygen tubing for
Resident #11 was dated 10/17/23. She verified it had not been changed the night before.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 9 of 11
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
10/25/2023
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 0695
This deficiency represents non-compliance investigated under Complaint Number OH00146827.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 10 of 11
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
10/25/2023
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on record review, interview and policy review the facility failed to ensure narcotic medication were
reconciled each shift for medication carts two and three. This affected 10 residents (Resident #3, #5, #8,
#23, #24, #25, #29, #30, #31, #33) who received narcotic medication from medication cart two and three.
The facility census was 31.
Findings included:
Review of the narcotic reconciliation sheet for medication cart two revealed no documentation the shift to
shift narcotic reconciliation was completed on 10/11/23, 10/16/23, 10/17/23 and 10/18/23.
Review of the narcotic reconciliation sheet for medication cart three revealed no documentation of the
shift-to-shift narcotic reconciliation was completed on 10/13/23, 10/17/23 and 10/18/23.
On 10/18/23 at 9:20 A.M. an interview with Registered Nurse #100 revealed she had completed the
narcotic count with the night shift nurse but the night shift nurse was in a hurry and never documented
narcotic reconciliation had occurred.
On 10/19/23 at 9:00 A.M. an interview with the Director of Nursing verified the narcotic count/reconciliation
sheets did not indicate narcotic count was completed on the dates identified. She stated the nurses were to
count and document the narcotic count was completed at every shift change.
Review of the facility policy titled, Narcotic Accountability, dated 03/17 revealed all drugs with abuse
potential were stored and monitored properly and accurate record keeping maintained. All controlled
substances were to be counted each shift or whenever there was an exchange of keys between off-going
and on-coming licensed nurses.
This deficiency represents non-compliance investigated under Complaint Number OH00146827.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 11 of 11
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
FAQ · About this visit
Common questions about this visit
What happened during the October 25, 2023 survey of ST LUKE LUTHERAN COMMUNITY-PORTAGE LAKES?
This was a inspection survey of ST LUKE LUTHERAN COMMUNITY-PORTAGE LAKES on October 25, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ST LUKE LUTHERAN COMMUNITY-PORTAGE LAKES on October 25, 2023?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.