Inspection·January 29, 2025

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 record review and interview the facility failed to ensure wound care treatments were completed timely and per physician orders for Resident #41. This affected one resident (Resident #41) out of three residents reviewed for wound care. The faciltiy census was 40. Residents Affected - Few Findings include: Review of Resident #41's medical record revealed an admission date of 12/13/24 and a discharge date of 12/21/24. Diagnosis included cellulitis of right lower extremity, sepsis, fracture of right tibia, type two diabetes, atrial fibrillation, rash, head laceration, wedge compression fracture of T4, ulcerative colitis, age related osteoporosis, nicotine dependency, and gastroesophageal reflux disease. Review of Resident #41's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 had intact cognition. They required supervision or touching assistance for eating, set up or clean up assistance for bed mobility, and partial to moderate assistance for oral hygiene, toileting, showers, dressing and personal hygiene. Review of Resident #41's care plan revealed there was a care plan initiated related to Resident #41 was at risk for skin breakdown due to impaired balance, fractured right lower extremity, head laceration, and multiple medical conditions. Interventions including supervision for showering, barrier cream after each incontinence episode and as needed, float heels when in bed if the resident allows, turn and reposition every two hours and as needed, pressure reduction mattress, and anticipate the residents needs. There was a care plan initiated on 12/17/24 related to venous stasis ulcers to lower extremities related to CHF with no interventions or goals listed. Review of Resident #41's physician orders dated 12/17/24 revealed orders to clean the right foot venous wounds with normal saline, apply mesalt and cover with boarder foam dressing every day and as needed, and a physician order dated 12/19/24 to cleanse right leg venous wounds with normal saline, apply Dakins moistened gauze to wounds, cover with ABD pad and wrap with kerlix every day. Review of Resident #41's Treatment Administration Record (TAR) dated December 2024 revealed the residents treatments were not completed on 12/17/24, 12/18/24 and 12/21/24. Interview on 01/28/25 at 10:35 A.M. with Licensed Practical Nurse (LPN) #803 revealed there were issues with LPN #805 completing Resident #41's treatments as ordered and was ultimately fired for not doing them. Interview on 01/28/25 at 12:39 P.M. with the Director of Nursing and the Assistant Director of Nursing (ADON) revealed LPN #805 was educated and disciplined multiple times for not completing Resident #41's treatments as ordered and was terminated on 12/22/24 for insubordination related to not completing the treatments for Resident #41 as ordered and instructed to by the DON. The DON and the ADON both confirmed treatments were not completed by LPN #805 on 12/17/24, 12/18/24 and 12/21/24. Review of LPN #805's employee file revealed she was terminated on 12/22/24 due to insubordination and for not completing treatments for Resident #41 as instructed to do by the DON. (continued on next page) 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 01/29/2025 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 This deficiency represents noncompliance identified during investigation of Complaint Number OH00160998. 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 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 01/29/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the residents medical record was complete and reflected treatment orders put in place for wound care. This affected one resident (Resident #1) of three residents reviewed for wound care. The facility census was 40. Findings Include: Review of Resident #1's medical record revealed an admission date of 12/05/16. Diagnoses included dementia, cerebral infarction, ataxia, diabetes mellitus, anxiety disorder, seizures, drug induced subacute dyskinesia, muscle wasting and atrophy. Review of Resident #1's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #1 required supervision or touching assistance for eating, substantial to maximal assistance for bed mobility, and was dependent on staff for oral hygiene, toileting, showers, dressing, and personal hygiene. Review of the facility document titled Provider Consultation, dated 12/05/24 and authored by WCNP #807 revealed the WCNP #807 had been consulted for a new wound to the coccyx for evaluation and treatment for Resident #1. A treatment for Santyl for enzymatic debriding, alginate, bordered foam dressing everyday and as needed was the treatment ordered and signed on 12/09/24 by the WCNP #807. Review of Resident #1's care plan revealed there was no care plan triggered to address the wound to the coccyx and the recommended treatment by the WCNP. Review of Resident #1's physician orders dated for December 2024 and January 2025 revealed the orders put in place by WCNP #807 were not transcribed into the Electronic Medical Record (EMR) physician orders. Review of Resident #1's Treatment Administration Record (TAR) dated December 2024 and January 2025 revealed there was no order or documentation of treatment for the wound to the residents coccyx. Review of Resident #1's nurse progress notes dated from 12/09/24 through 01/28/25 revealed nursing staff were monitoring and completing the treatment to Resident #1's coccyx as recommended by WCNP #807. Review of Resident #1's facility weekly wound care assessments for December 2024 and January 2025 revealed the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) monitored, assessed and measured the residents wound weekly. Observation made on 01/28/25 at 10:20 A.M. of wound care for Resident #1 by Licensed Practical Nurse (LPN) #803 with help from Certified Nursing Assistant (CNA) #804 revealed all infection control measures were followed, and the treatment recommended by the WCNP was being followed. Interview on 01/28/25 at 10:35 A.M. with LPN #803 revealed she completed wound care for Resident #1 per orders put in place by WCNP #807. When asked to show the survey where the wound care orders were in the EMR physician orders, LPN #803 confirmed the orders were never transcribed from WCNP #807's (continued on next page) 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 01/29/2025 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 0842 weekly assessments. Level of Harm - Minimal harm or potential for actual harm Interview on 01/28/25 at 12:39 P.M. with the DON and the ADON revealed they confirmed treatments for Resident #1 were being completed as noted in the progress notes however the physician orders and the TAR did not reflect the orders put in place by WCNP #807 on 12/09/24. They confirmed the orders were never transcribed into the EMR. They stated they had completed all weekly wound care assessments and monitored, assessed and measured the residents wounds and communicated with WCNP #807 if needed. Residents Affected - Few Interview on 01/29/25 at 11:15 A.M. with the WCNP #807 regarding Resident #1 revealed she put all her orders on her assessments which were provided to the facility so it would be up to the facility to ensure her orders were entered into the physician orders in the EMR. She stated if there were changes to the orders she communicated them to the nursing staff. Interview on 01/29/25 at 11:30 A.M. with Registered Nurse (RN) #808 revealed they completed wound care for Resident #1 when assigned to the resident and would enter what care was provided into a nurse progress note. This deficiency represents noncompliance identified during investigation of Complaint Number OH00160998. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366280 If continuation sheet Page 5 of 5