Saint Luke Lutheran Home

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice

before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, interview, and policy review the facility failed to ensure resident representatives received room change notification. This affected one resident (#121) of three residents reviewed for family notifications. The census was 129.Findings include: Review of the medical record for Resident #121 revealed an admission date of 06/07/23. Diagnoses included but not limited to acute kidney failure, dementia, and unspecified psychosis. Resident #121 resided on the secured, locked, memory care unit.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident scored a 14 out of 15 on the Brief Interview Mental Status (BIMS) indicating intact cognition.Review of Resident #121's medical record revealed a progress note dated 10/10/25 at 11:13 A.M., late entry, the patient was moved from (current room) to (current room) and was showered and changed.There was no indication in the medical record Resident #121's representative received notification of the room change.Interview on 11/18/25 at 4:09 P.M. via phone with prior Director of Nursing (DON) #495 revealed

the room change occurred right before he left and reported he was told it was taken care of.Interview with Resident #121 on 11/19/25 at 6:38 A.M. revealed in October (2025) she had a room change due to bed bugs and she liked her new room. Interview on 11/19/25 at 9:34 A.M. via phone with Nurse Practitioner (NP) #501 confirmed she was not notified by the facility regarding Resident #121's room change due to bed bugs.Interview on 11/19/25 at 10:06 A.M. via phone with Nurse Practitioner (NP) #500 confirmed he was not notified by the facility regarding Resident #121's room change due to bed bugs.Interview on 11/19/25 at 10:21 A.M. with Resident #121's son via phone confirmed he was not notified by the facility of his mother's room change due to bed bugs. The son further stated he received a call from two females at the facility the day before (11/18/25) asking if he had been notified by the facility of Resident #121's room change due to bed bugs. He reported he thought it was weird and told them he was not notified of the room change due to bed bugs. The son stated the DON apologized for the poor communication. Interview on 11/19/25 at 11:36 A.M. with Licensed Practical Nurse (LPN) #459 confirmed she discovered the bed bugs and immediately notified the prior DON #494, who told her he would take care of notification. LPN #459 confirmed she did not notify Resident #121's family regarding the room change due to bed bugs.Review of the facility policy, Room Change/Roommate Assignment, revised March 2021, revealed prior to changing a room or roommate assignment all parties involved in the change/assignment, (to include the residents and their representatives) are given at least a day notice of such change.This deficiency represents non-compliance investigated under Complaint Number 2646189.

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

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If continuation sheet

Event ID:

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

11/24/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observation, interview, policy review and review of material safety data sheet (MSDS), the facility failed to ensure possible hazardous areas and materials were properly secure on the memory care unit.

This had the potential to affect 25 residents (#2, #8, #10, #12, #16, #30, #38, #39, #40, #45, #54, #60, #64, #65, #71, #79, #87, #89, #92, #94, #100, #115, #118, #121, and #129) that were able to ambulate and propel in wheelchairs on the memory care unit. Facility census was 129.Findings include:An observation of

the memory care unit on 11/17/25 at 12:06 P.M. revealed the door to the soiled utility room located on Somerset Hall was unlocked. The soiled utility room had barrels for soiled linens and trash. Several wheelchairs and other equipment were located in the soiled utility room. An observation of the memory care unit on 11/18/25 at 2:31 P.M. revealed the door to the clean utility room located on Greenbriar Hall was unlocked. There were two containers with 160 wipes in each of Microkill Germicidal Wipes The shelving unit would be accessible to residents standing or sitting in a wheelchair. The wipes was labeled to keep out of

the reach of children. An interview on 11/18/25 at 2:39 P.M. Housekeeping Supervisor #265 verified the door to the clean utility room was unlocked and items marked to keep out of the reach of children were within reach in the unlocked room. The supervisor verified the residents should not be able to access chemicals. Review of the MSDS Sheet revealed if ingested, rinse mouth and do not induce vomiting. Obtain emergency medical attention.Hazardous Areas, Devices and Equipment policy (no date) revealed all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard is defined as anything

in the environment that has the potential to cause injury or illness. Examples of environmental hazards included equipment and devices that are left unattended, open areas or items that should be locked when not in use, access to toxic chemicals, and disabled locks, latches, or alarms. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. The safety committee will recommend measures to ensure that vulnerable residents cannot access hazardous areas in the facility. The safety committee will periodically check for the implementation and integrity of measures intended to prevent residents from accessing hazardous areas.

This deficiency represents non-compliance investigated under Complaint Number 2651378.

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

11/24/2025

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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Avycaz was administered to Resident #81 on 10/25/25 at 2:00 P.M.The Medicare 5-day Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #81 was cognitively intact, and medications included the administration of antibiotics.An interview on 11/20/25 at 9:22 A.M. with the Administrator verified the pharmacy requested authorization to bill the facility for Avycaz, and the previous DON did not address the authorization in a timely manner resulting in missed doses of intravenous medication. An interview on 11/20/25 at 9:57 A.M. with Admission/Marketing #445 revealed the Printable Discharge Form was communication between himself and the hospital case managers. Admission/Marketing #445 verified the facility was notified Resident #81 required intravenous antibiotics and Avycaz was expensive and the facility would admit Resident #81. An interview on 11/24/25 at 8:05 A.M. the current DON stated she was not the DON in October 2025. The current DON verified the medical record revealed Avycaz was discussed prior to Resident #81 being admitted . Current DON also verified the medical record revealed the admission order was for ceftazidime, but ceftazidime did not come in the dosage ordered and Avycaz had to be ordered to get the correct dosage. The current DON stated the previous DON did not address the concerns with the correct dosage and approval for the medication to be sent to the facility for Resident #81 resulting in a treatment delay due to not receiving the ordered antibiotics timely. An interview on 11/24/25 at 8:27 A.M.

Pharmacy Technician #504 revealed ceftazidime did not come in the ordered 1.25-gram dose but Avycaz was available in 1.25 grams. Pharmacy Technician #504 stated LPN #477 discontinued the ceftazidime because Resident #81 was receiving Daptomycin. Pharmacy Technician #504 also stated the delay of the ceftazidime and/or Avycaz could have been due to cost. An interview on 11/24/25 at 8:40 A.M. with LPN #477 stated upon admission the infectious disease doctor wrote a prescription for ceftazidime 1.25 grams.

Pharmacy sent the ceftazidime, but it was for one gram instead of 1.25 grams. Pharmacy was contacted and stated ceftazidime was only available in one or two grams, but Avycaz was available in 1.25 grams.

LPN #477 stated she contacted the infectious disease doctor. The infectious disease ordered Avycaz 1.25 grams. LPN #477 stated she did not discontinue the ceftazidime due to Resident #81 already receiving Daptomycin. LPN #477 stated the ceftazidime 1.25 grams was discontinued and the Avycaz 1.25 grams was ordered after clarification from the infectious disease doctor. LPN #477 verified she was the nurse working when there were problems getting ceftazidime and Avycaz. LPN #477 stated she reported daily to

the DON and ADON about ceftazidime and Avycaz not being available. LPN #477 stated it was a pattern with the previous DON and ADON to not address concerns the nurses had. This deficiency represents non-compliance investigated under Complaint Number 2661530.

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