Saint Luke Lutheran Home

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

week now. Interview on 09/10/25 at 3:10 P.M. with the Director of Nursing (DON) verified the concerns with

the facility not having enough towels and washcloths available. The DON revealed the facility had hired a new Laundry/Housekeeper employee (#506). Interview on 09/10/25 at 3:59 P.M. with Laundry/Housekeeping Supervisor #506, who just started a three days ago confirmed there were not enough towels and washcloths for the facility. Review of the facility policy, Housekeeping - Supplies and Equipment, revised 12/2024, revealed the Housekeeping Supervisor maintains all supplies and keeps equipment stocked. 3. Interview/observation on 09/10/25 from 10:57 A.M. to 11:01 A.M. with LPN #331 revealed resident's were not being provided garbage bags in the trash cans in their rooms and that this had been a new change in the facility. Observation of Resident #40, #48, #44 and #32's room with LPN #331 verified the lack of garbage bags in the trash cans in these resident's rooms. Interview on 09/10/25 at 9:45 A.M. with Resident #40's family reported the facility had stopped supplying garbage bags for the trash can

in the resident's room about a week ago. Interview on 09/10/25 at 3:10 P.M. with the DON confirmed the facility was having issues with not having enough garbage bags and running out. The DON reported a new Laundry/Housekeeper employee (#506) had been hired. Interview on 09/10/25 at 3:59 P.M. with Laundry/Housekeeping Supervisor #506, who just started a three days ago confirmed the facility had issues with not having enough garbage bags and running out.Interview on 09/11/25 at 9:10 A.M. with Housekeeper (HK) #407 confirmed there were no trash bags available to for use in resident rooms on the units. Interview on 09/11/25 at 12:13 P.M. with CNA #353 revealed issues with not having enough garbage bags for over a month now.Review of the facility undated document titled Housekeeper revealed when cleaning resident rooms, empty trash cans and reline.Review of the facility policy, Housekeeping - Supplies and Equipment, revised 12/2024, revealed the Housekeeping Supervisor maintains all supplies and keeps equipment stocked. This deficiency represents non-compliance investigated under Master Complaint Number 2611431 and Complaint Number 2579316.

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Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Luke Lutheran Home

220 Applegrove Street NE North Canton, OH 44720

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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, interview, and facility policy review, the facility failed to ensure care plans were comprehensive. This affected three residents (Resident #62, #93, and #125) of 10 residents reviewed for care plans. Facility census was 124. Findings include: 1. Review of the medical record for Resident #62 revealed an admission date of 08/02/25 and diagnoses included pneumonia. Review of the quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #62 had impaired cognition. Review of the physician order dated August 2025 revealed Resident #62 received Eliquis (anticoagulant) 5 milligram (mg) one (1) tablet in the morning and 1 tablet in the evening (HS).Review of the care plan dated 08/02/25 revealed there was no care plan for anticoagulant therapy.Interview on 08/28/25 at 10:27 A.M. with Minimum Data Set (MDS) Registered Nurse (RN) #260 confirmed there was no anticoagulant therapy care plan for Resident #62 and there should have been. Review of facility policy, Care Plans, Comprehensive, Person-Centered, revised 02/2025, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.2.Review of the medical record for Resident #93 revealed an admission date of 02/13/25. Diagnoses included surgical amputation.Review of the quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #93 had intact cognition. Review of the physician order dated August 2025 revealed Resident #93 received Apixaban (anticoagulant) 2.5 MG give 1 tablet by po twice a day (BID) and give Clopidogrel Bisulfate 75 MG give 1 tablet PO in the morning.Review of the care plan dated 03/10/25 revealed there was no care plan for anticoagulant therapy.Interview on 08/28/25 at 10:27 A.M. with MDS RN #260 confirmed there was no anticoagulant therapy care plan for Resident #93 and there should have been. Interview on 08/28/25 at 10:27 A.M. with Registered Nurse (RN) #260 confirmed there were no anticoagulant care plans for Resident #93 and there should be.3. Review of the closed medical record for Resident #125 revealed an admission date of 07/16/25 and a discharge date of 07/31/25. Diagnosis included but not limited to fracture of sacrum pubis, and wedge compression fracture of T11-T12 Vertebra, malignant neoplasm of glottis, and chronic venous hypertension with ulcer of left lower extremity.Review of the Medicare five-day Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #125 had intact cognition. Review of the physician order dated July 2025 revealed Resident #125 was ordered Plavix 75 MG (anticoagulant) give 1 table PO in the morning.Review of the care plan dated 04/25/25 revealed there was no care plan for anticoagulant therapy.Interview on 08/28/25 at 10:27 A.M. with MDS RN #260 confirmed there was no anticoagulant therapy care plan for Resident #125 and there should have been.Review of facility policy, Care Plans, Comprehensive, Person-Centered, revised 02/2025, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.This is an incidental finding discovered during the complaint investigation.

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Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Luke Lutheran Home

220 Applegrove Street NE North Canton, OH 44720

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record reviews, care conference postcard and letter invitation review, interviews and policy review the facility failed to ensure care plan meetings were offered timely, per preference, and in person. This affected one (Resident #40) of three residents reviewed for care plan meetings. The facility census was 124.Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/16/22. Diagnoses included but not limited to encephalopathy, bipolar disorder, schizophrenia, psychosis and dementia. with behavioral disturbance.Review of the quarterly minimum data set (MDS) dated [DATE REDACTED], revealed Resident #40 scored a zero on the brief interview mental status (BIMS) out of 15, resulting in severely impaired cognition. Resident #40 was dependent on staff for all her care needs to include toileting, showering, and eating.Interview on 09/10/25 at 9:45 A.M. with Resident #40's family member revealed she was not offered any care conferences in over five (5) months with the last care conference she had was over the phone on 03/18/25. She reported she usually received a letter in the mail to have the care conference over the phone but she has not received a letter in over 5 months and she would like to have

the care conference in person. The family member stated the facility only offers care conference meetings over the phone. Interview on 09/11/25 at 7:43 A.M. with the Director of Nursing (DON) confirmed care plan meetings are to be held on admission, quarterly, annually, with significant change, and if the family requests. DON confirmed no evidence a care conference letter was mailed to Resident #40's family or RSVP received by the facility. DON reported the facility verbally calls or emails resident families to schedule care conferences. DON reported resident families have the choice of over the phone or in person care conference. Interview on 09/11/25 at 9:42 A.M. with Licensed Social Worker (LSW) #254 confirmed care plan meetings are to be held every quarter. LSW #254 confirmed Resident #40's last care conference was

on 03/18/25 and did not have an RSVP for the 06/18/25 care plan meeting. LSW #254 confirmed letters are mailed for over the phone care plan meetings only and was unable to verify the resident's family member received a letter for the 06/18/25 meeting.Review of the facility document letter sent to residents ' families for care conferences revealed an invitation to attend care conference, stating at this time we are doing

these meetings via telephone in lieu of in-house meetings. The letter further stated to call LSW #254 to RSVP if you were planning on attending or need to reschedule.Review of the facility documents/post card provided to residents regarding care plan meetings revealed residents are invited to attend, the meeting will be over the phone, and the resident was to notify front desk if they plan to attend.Review of facility policy, Care Plans, Comprehensive, Person-Centered, revised 02/20/25, revealed each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, to include participation.This deficiency represents non-compliance investigated under Master Complaint Number 2611431.

Event ID:

Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Luke Lutheran Home

220 Applegrove Street NE North Canton, OH 44720

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on interviews and closed medical record review, the facility failed to ensure physician orders were followed and the physician was contacted with elevated blood pressure findings. This affected one resident (125). The facility census was 124.Findings included: Review of the closed medical record for Resident #125 revealed an admission date of 07/16/25 and a discharge date home of 07/21/25. Diagnosis included but not limited to fracture of sacrum pubis, and wedge compression fracture of T11-T12 Vertebra, malignant neoplasm of glottis, and chronic venous hypertension with ulcer of left lower extremity.Review of the physician orders dated 07/16/25 for Resident #125 revealed an order for orthostatic blood pressure (BP) times (x) three (3) shifts every shift for lying BP, sitting BP, and standing BP.Review of the physician orders dated 07/17/25 for Resident #125 revealed an order for transfers: two person physical assist every shift.Review of the blood pressure readings for Resident #125 revealed on 07/17/25 at 1:07 A.M. lying blood pressure (BP) was 186/99 and sitting BP was 189/99. No standing BP was taken. On 07/18/25 there were no BP readings recorded. On 07/19/25 at 1:21 P.M. a sitting BP of 191/81, no lying or standing BP was taken. On 07/20/25 at 6:21 P.M. a lying BP reading of 151/67 was taken, no sitting or standing BP was taken. On 07/21/25 at 8:14 A.M. lying BP was 210/104, and on 07/21/25 at 8:08 P.M. sitting BP was 144/84, no standing BP was recorded. On 07/22/25 at 5:20 A.M. a lying BP reading was 192/92 and on 07/22/25 at 1:07 P.M. sitting BP was 163/101, no standing BP reading done. On 07/24/25 at 3:02 P.M. a sitting BP reading was 145/101 and on 07/23/25 at 9:12 P.M. a sitting BP reading was 152/96, no lying or standing BP ' s were recorded. On 07/24/25 at 8:07 A.M. a sitting BP reading of 144/86 and on 07/24/25 at 9:06 P.M a sitting BP reading of 145/85 was recorded. On 07/25/25 at 1:50 P.M. a lying BP of 142/76 was recorded. On 07/26/25 at 06:54 A.M. a sitting BP reading of 178/89 was recorded and on 07/26/25 at 11:22 A.M. a sitting BP reading of 173/86 was recorded. On 07/26/25 at 7:29 P.M. was sitting BP reading of 150/67 recorded.Review of the progress notes dated July 2025 for Resident #125 revealed no progress notes regarding notification to the physician regarding blood pressure readings. Review of the physician orders dated 07/24/25 revealed an order for Amlodipine Besylate (medication used to treat high BP) 5 milligram (mg) to give one (1) tablet by mouth (PO) daily for hypertension (high blood pressure).Review of the Medication Administration Records (MARS) and Treatment Administration Records (TARS) for July 2025 revealed on 07/24/25 Resident #125 received Amlodipine as ordered.Interview on 08/27/25 at 2:52 P.M. with the Director of Nursing (DON) confirmed physician orders were not followed for the orthostatic BP's to be taken lying, sitting, and standing. The DON confirmed for high BP's, the physician should be notified, and the nurse should document in the progress notes regarding the notification. Interview on 09/02/25 at 7:25 A.M. with Assistant Director of Nursing (ADON) #261 confirmed there was no notification to physician regarding the high blood pressure readings and the order upon admission for BP's to be taken, lying, sitting, and standing were not followed as ordered. Interview on 09/02/25 at 8:23 A.M. with Registered Nurse (RN) Coordinator #319 confirmed physician orders were not followed as ordered. RN Coordinator #319 confirmed for high BP's, the physician should be notified, and the nurse should document in the progress notes regarding the notification. The RN Coordinator confirmed a high blood pressure is anything over 140/70's.Interview on 09/02/25 at 10:01 A.M. with Physician #500 confirmed he wasn't notified of high BP readings for Resident #125. Physician #500 reported he would expect to be notified for a systolic (top number of a blood pressure reading) BP of 160 or above and a diastolic (bottom number of a blood pressure reading) BP reading of 90 or above. Physician #500 confirmed he expected nursing staff to follow his orders to include orthostatic BP readings, lying, sitting and standing.This is an incidental finding discovered during the complaint investigation.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Luke Lutheran Home

220 Applegrove Street NE North Canton, OH 44720

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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Based on observation, interviews and policy review, the facility failed to ensure meals were served timely

on the Memory Care Unit. This affected all 33 residents residing on the Memory Care Units (Resident #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, and #51). The facility Census was 124. Findings include:

Interview on 09/10/25 at 9:45 A.M. with Resident #40's family reported the food trays are always late to the dining room by almost an hour.Observation on 09/11/25 at 12:00 P.M of the dining room in Memory Care Unit revealed 17 residents were seated and awaiting their lunch meals.Interview on 09/11/25 at 12:13 P.M. with Certified Nursing Assistant (CNA) #353 confirmed meals are late.Interview on 09/11/25 at 12:13 P.M. with CNA #408 confirmed meals are late.Observation on 09/11/25 at 12:37 P.M. revealed the first meal cart arrived to the unit. Seven (7) staff (two unidentified staff and CNA #345, CNA #353, CNA #375, CNA #408, and Licensed Practical Nurse (LPN) #331) started passing the meal trays to the residents.Interview on 09/11/25 at 12:46 P.M. with CNA #375 confirmed meals are always late.Interview on 09/11/25 at 12:31 P.M. with Resident #38's family confirmed meals are late, usually at least 30 minutes late.Interview on 09/11/25 at 1:46 P.M. with Dietary Aide #270 confirmed the lunch meal trays were late.Interview on 09/11/25 at 1:46 P.M. with Dietary Manager #200 confirmed the lunch meal trays were late to Memory Care Unit and when asked what may cause the meal delivery to be late, stated staff are not timely serving up the trays.Interview

on 09/11/25 at 1:52 P.M. with Dietary Supervisor #406 confirmed the lunch meal trays were late to Memory Care Unit. When asked what causes the meals trays to be late coming from the kitchen the supervisor stated they were just late sometimes.Review of the policy, Meal Times, undated, revealed for the Memory Care Unit first meal cart to be delivered at 12:00 P.M., (Laurel Valley 1) and second meal cart to be delivered at 12:15 P.M., (Laurel Valley 2) for the lunch meal.Review of the facility policy, Food Palatability Policy, undated, revealed meal trays will be delivered promptly to ensure freshness and quality. This deficiency represents non-compliance investigated under Master Complaint Number 2611431.

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Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Luke Lutheran Home

220 Applegrove Street NE North Canton, OH 44720

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to implement infection control procedures during medication administration. This affected one resident (#100) of five residents observed for medication administration. The facility census was 124.Findings include: Review of record for Resident #100 revealed

an admission date of 08/20/22. Diagnosis included but not limited to volvulus, history of malignant neoplasm of the breast and skin, and absence of parts of the digestive tract and of both cervix and uterus.Review of the quarterly minimum data set (MDS) dated [DATE REDACTED] revealed Resident #100 had intact cognition.Review of the physician orders for August 2025 revealed Resident #100 was ordered Vitamin D3 50 microgram (mcg) give two capsules by mouth (PO) in the morning.Observation of medication administration on 08/28/25 at 8:15 A.M. revealed with Registered Nurse (RN) #316 administered Vitamin D3 50 mcg one capsule to Resident #100. RN #316 then realized the order was for Vitamin D3 50 mcg to administer two capsules. RN #316 administered Vitamin D3 50 mcg one capsule to Resident #100 and then went to the medication cart. RN #316 used hand sanitizer then removed the bottle of Vitamin D3 50 mcg from the medication cart and placed two (2) capsules in the medicine cup. RN #316 then realized she only needed one additional Vitamin D3 50 mcg capsule. RN #316 removed one Vitamin D3 capsule from the medicine cup with her bare hands, touching the other Vitamin D3 in the medicine cup and placed the Vitamin D3 she removed from the medicine cup, back into the Vitamin D3 bottle with the other pills remaining in the bottle. RN #316 then administered Vitamin D3 50 mcg one capsule to Resident #316.

Interview on 08/28/25 at 8:27 A.M. with RN #316 confirmed she used her bare hands to remove one Vitamin D3 capsule from the medicine cup, touching the remaining one Vitamin D3 capsule and put the removed Vitamin D3 in the original medication bottle. RN #316 reported she didn't think she did anything wrong because she used hand sanitizer prior to touching the Vitamin D3 capsules.Interview on 08/28/25 at 9:22 A.M. with the Director of Nursing (DON) confirmed staff were not to use their bare hands to touch resident medication and not return the medication to the original bottle. The DON reported he would discard

the Vitamin D3 medication bottle.Interview on 08/28/25 at 10:41 A.M. with RN Nursing Coordinator #319 confirmed nurses are not to touch pills with their bare hands, they should use gloves.Review of facility policy, Infection Prevention and Control Program, undated, revealed It is a policy of this facility to establish and maintain an infection prevention ad control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. This deficiency is an incidental finding discovered during the investigation.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Luke Lutheran Home

220 Applegrove Street NE North Canton, OH 44720

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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

today. On [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED] staff documented there was no hot water. On [DATE REDACTED] the form was blank. Documentation on [DATE REDACTED] and [DATE REDACTED] revealed no hot water today ([DATE REDACTED]) water temperatures in the 90's. On [DATE REDACTED] and [DATE REDACTED] staff documented water temperatures between 90 and 101 degrees Fahrenheit.Interview on [DATE REDACTED] at 10:58 A.M. with Maintenance Tech (MT) #380 revealed the facility was operating on one boiler for hot water and the kitchen and laundry would get the hot water first.

They would use all the hot water leaving the rest of the building without hot water. The boiler system would try to catch itself up overnight. The kitchen had a single booster to the dishwasher to ensure they were meeting metrics for dishwashing but they weren't having hot water for cooking. Laundry was having a hard time getting hot water past 90 degrees Fahrenheit (F). The facility swapped to a different chemical system

before the boiler system issue so the bleach offset the lack of hot water. During the interview, the MT revealed the main section of the facility building ran on three boilers, with the memory care unit, dogwood unit and rehab unit on a completely different operating system which he thought was fully functional MT #380 revealed when going through the timeline of previously reported (beginning in [DATE REDACTED]) hot water issues, they would check water in the morning and in identifying hot water issues they would look to find the issue to fix. In [DATE REDACTED] they identified the boiler kept tripping with an electric short and it would pop the breaker so they would start it back up and get hot water temps restored. They would then find the housekeeping mixing dispensers were not always turned off, leading to lower hot water. MT #380 revealed

in [DATE REDACTED], the facility had a hot water holding tank bust and a company came in to cut it out and the facility was able to use the other holder tanks. Ongoing issues in [DATE REDACTED] required repairs to the boiler system including valve and circulation pump replacement. MT #380 revealed they facility had a three boiler system for years and almost a year ago they pulled one boiler that went down so they were working with the remaining two boilers (a main boiler and a back up boiler). Maintenance Tech #380 believed the facility would need to get quotes to fix the whole system, by they didn't go through, or it was put off, and eventually

the second boiler died at the beginning of [DATE REDACTED] leaving only one boiler. Review of facility policy, Water Temperatures, Operational Manual - Physical Environment, revised [DATE REDACTED], revealed the facility ensures water was maintained at temperatures suitable to meet residents needs. Tap water in the facility was maintained within a temperature range to prevent scalding of residents. The policy further revealed water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas were set to temperatures of at least 105 degrees Fahrenheit (F) and no more than 120-degree F.This deficiency represents non-compliance investigated under Master Complaint Number 2579316.

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Facility ID:

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