Health inspection·November 27, 2024

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. Page 1 of 4 366280 366280 11/27/2024 St Luke Lutheran Community-Portage Lakes 615 Latham LN Akron, OH 44319

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 366280 Page 2 of 4 366280 11/27/2024 St Luke Lutheran Community-Portage Lakes 615 Latham LN Akron, OH 44319

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 366280 Page 3 of 4 366280 11/27/2024 St Luke Lutheran Community-Portage Lakes 615 Latham LN Akron, OH 44319

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. 366280 Page 4 of 4