Lutheran Home
Inspection Findings
F-Tag F0694
F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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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LUTHERAN HOME in WESTLAKE, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WESTLAKE, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LUTHERAN HOME or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.