F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interview, the facility failed to
provide the correct Quality Improvement Organization (QIO) information to residents who were completing
therapy. This affected three (Resident #145, Resident #146 and Resident #147) of three reviewed for
liability notices. The census was 37.
Residents Affected - Few
Findings include:
1. Review of Resident #145's medical record revealed they were readmitted to the facility on [DATE]. A
Notice of Medicare Non-Coverage letter revealed services were ended on 09/26/24. The letter did not
provide the correct QIO information.
Interview on 11/27/24 at 11:45 A.M. with the Administrator and Social Service Designee #240 verified the
letters to the residents did not provide the correct QIO information.
2. Review of Resident #146's medical record revealed they were admitted to the facility on [DATE]. A Notice
of Medicare Non-Coverage letter revealed services were ended on 08/31/24. The letter did not provide the
correct QIO information.
Interview on 11/27/24 at 11:45 A.M. with the Administrator and Social Service Designee #240 verified the
letters to the residents did not provide the correct QIO information.
3. Review of Resident #147's medical record revealed they were admitted to the facility on [DATE]. A Notice
of Medicare Non-Coverage letter revealed services were ended on 02/20/24. The letter did not provide the
correct QIO information.
Interview on 11/27/24 at 11:45 A.M. with the Administrator and Social Service Designee #240 verified the
letters to the residents did not provide the correct QIO information.
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
11/27/2024
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record reviews, review of shower documentation and interviews the facility failed to ensure residents
received adqueate assistance with activities of daily living to completed showers as scheduled. This
affected three residents (Resident #15, Resident #25 and Resident #29) of three residents reviewed for
showers. The census was 37.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #15 revealed an admission date of 07/22/22. Diagnoses
included complete lesion at T-7 through T-10 level of thoracic spinal cord, neuromuscular dysfunction of
bladder and hypotension. The resident was cognitively intact.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was dependent
for showers.
Review of the shower sheets for the last 60 days revealed showers were offered or given on 09/09/24,
09/11/24, 11/07/24 and 11/25/24.
Interview on 11/25/24 at 10:06 A.M. with Resident #15 revealed he did not getting showers as scheduled.
Interview on 11/26/24 at 6:30 P.M. with the Director of Nursing verified there was a lack of evidence
showers were given twice a week as scheduled for Resident #15.
2. Review of the medical record for Resident #25 revealed an admission date of 11/18/21. Diagnoses
included Down Syndrome, difficulty walking and anxiety disorder. The resident was cognitively impaired.
Review of the quarterly MDS assessment dated [DATE] revealed she was dependent for showers.
Review of the shower sheets revealed showers were offered or given on 10/07/24, 10/29/24, 11/01/24,
11/15/24, 11/19/24, 11/20/24, 11/22/24.
Interview on 11/26/24 at 6:30 P.M. with the Director of Nursing verified there was a lack of evidence
showers were given twice a week as scheduled for Resident #25.
3. Review of the closed medical record for Resident #29 revealed an admission date of 11/01/24.
Diagnoses included radiculopathy lumbar region, type 2 diabetes mellitus and hyperlipidemia. The resident
was cognitively intact.
Review of the 5-day MDS assessment dated [DATE] revealed he was dependent for showers.
Review of the shower sheets since admission revealed a shower was given on 11/05/24.
Interview on 11/25/24 at 11:37 A.M. with Resident #29 revealed he did not get showers as scheduled.
Interview on 11/26/24 at 6:30 P.M. with the Director of Nursing verified there was a lack of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 2 of 4
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
11/27/2024
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 0677
evidence showers were given twice a week as scheduled for Resident #29.
Level of Harm - Minimal harm
or potential for actual harm
This deficiency represents non-compliance investigated under Complaint Number OH00159785.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 3 of 4
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
11/27/2024
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 0800
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional
and special dietary needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interviews the facility failed to ensure Resident #29 received meals as scheduled to meet
their dietary needs. This affected one resident (Resident #29) of three residents reviewed for meal service.
Findings include:
Review of the medical record for Resident #29 revealed an admission date of 11/01/24. Diagnoses included
radiculopathy of lumbar region, type 2 diabetes mellitus and hyperlipidemia. He was on a regular diet with
thin liquids.
Review of the 5-day Minimum Data Set assessment dated [DATE] revealed he was cognitively intact.
Interview on 11/25/24 at 11:37 A.M. with Resident #29 revealed he was not served breakfast one day and
lunch another day but couldn't recall the dates.
Interview on 11/26/24 at 4:00 P.M. with the Food Service Director #213 revealed she was off the day
Resident #29 was admitted and therefore there was no diet card created for him. She stated she believed
he missed at least two meals from the kitchen.
Interview on 11/26/24 at 6:30 P.M. with the Director of Nursing revealed Resident #29 missed breakfast and
missed a dinner but could not identify the dates.
Review of the concern log revealed Resident #29 had a concern on 11/04/24 that a dinner tray was not
served timely. The resolution was the facility was called and the facility retrieved him food from an outside
source.
This deficiency represents non-compliance investigated under Complaint Number OH00159785.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366280
If continuation sheet
Page 4 of 4
