Lutheran Home
LUTHERAN HOME in WESTLAKE, OH — inspection on November 24, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
admitted to the facility with IV access to administer IV ATB to treat a urinary tract infection.
The ADON noted Resident #70 went to multiple infusion appointments during admission.
The ADON stated she was notified by infusion clinic that Resident #70's PICC line dressing had not been changed at the facility.
The ADON stated LPN #800 and Agency LPN #801 signed off on the treatments in Resident #70's MAR/TAR without actually completing the dressing change.
The ADON indicated she was unable to recall the exact date on the dressing, however stated it was not changed for about two weeks.
The ADON stated LPN #800 was written up and Agency LPN #801 was marked on the do not return (DNR) list.
The ADON stated Resident #70 had no adverse effects of missing two dressing changes that she was aware of.
The ADON indicated it was the policy of the facility to change IV site dressings every Sunday.Interview on 11/24/25 at 12:52 P.M. with Agency LPN #801 revealed it was the weekend when she picked up a shift at the facility.
Agency LPN #801 stated she had requested dressing supplies for Resident #70's PICC line from the supervisor; however, the supervisor did not return with the dressing supplies.
Agency LPN #801 did not recall or provide additional information related to Resident #70.Interview on 11/24/25 at 2:29 P.M. with LPN # 800 revealed the nurse confirmed she had received disciplinary action related to not completing Resident #70's PICC line dressing changes. LPN #800 stated she thought she had completed all the dressings on her assignment, including Resident #70's. LPN #800 also stated she had to do an in-service on PICC line site care. LPN #800 did not recall or provide additional information related to Resident #70.Review of Coaching/Counseling/Corrective Action Form dated 09/10/25 revealed LPN # was given a written warning for signing off the TAR that she changed a treatment however it was discovered the dressing had not been changed since 08/21/25. It was noted on the form that the dressing was to be changed weekly.
Review of the facility policy Catheter Insertion and Care dated January 2019 revealed to assess the insertion site for complications at each dressing change.
Care instructions included to apply a sterile transparent dressing over the insertion site and to label and date the dressing.
There was no indication within the policy of frequency of dressing changes.This deficiency represents non-compliance investigated under Complaint Number 2650038.
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