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LUTHERAN HOME Inspection Report, Violations & Safety Grade (WESTLAKE, Ohio)

2116 DOVER CENTER RD, WESTLAKE, Ohio 44145

Phone: 4408710090

CMS Overall:5/5

Overview & Bed Count

Certified Beds
40
Avg Residents/Day
42.1
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Cuyahoga
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall5/5
Health5/5
Staffing4/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityOhio AvgDifference
RN Hours per Resident per Day0.700.64+0.06
Total Nurse Hours per Resident per Day5.943.71+2.22
CMS Staffing Rating4/52.4/5-
Nursing Staff Turnover50.0%49%-

Health Citation History

10 health citations on record

DateCategoryDescriptionSeverity
2026-07-16Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.D – Moderate Harm Potential
2026-07-16Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2025-11-24Quality of Life and Care DeficienciesProvide for the safe, appropriate administration of IV fluids for a resident when needed.D – Moderate Harm Potential
2023-08-24Freedom from Abuse, Neglect, and Exploitation DeficienciesEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.D – Moderate Harm Potential
2023-08-24Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2023-08-24Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.D – Moderate Harm Potential
2023-08-24Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.D – Moderate Harm Potential
2023-08-24Administration DeficienciesConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.C – Minimal Harm Potential
2023-08-24Administration DeficienciesHave the Quality Assessment and Assurance group have the required members and meet at least quarterlyC – Minimal Harm Potential
2020-01-16Infection Control DeficienciesProvide and implement an infection prevention and control program.F – Moderate Harm Potential

Fire Safety Citation History

17 fire safety citations on record

DateCategoryDescriptionSeverity
2023-08-24Emergency Preparedness DeficienciesDevelop Emergency Preparedness policies and procedures.F – Moderate Harm Potential
2023-08-24Miscellaneous DeficienciesProvide a written emergency evacuation plan.F – Moderate Harm Potential
2023-08-24Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2023-08-24Egress DeficienciesAdd doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.E – Moderate Harm Potential
2023-08-24Egress DeficienciesProvide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.E – Moderate Harm Potential
2023-08-24Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2023-08-24Smoke DeficienciesInstall an approved automatic sprinkler system.E – Moderate Harm Potential
2023-08-24Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2023-08-24Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2023-08-24Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2023-08-24Services DeficienciesHave properly installed electrical wiring and gas equipment.E – Moderate Harm Potential
2023-08-24Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.E – Moderate Harm Potential
2023-08-24Miscellaneous DeficienciesHave restrictions on the use of highly flammable decorations.E – Moderate Harm Potential
2023-08-24Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.E – Moderate Harm Potential
2020-01-16Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2020-01-16Egress DeficienciesKeep aisles, corridors, and exits free of obstruction in case of emergency.E – Moderate Harm Potential
2020-01-16Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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