Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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, record review and interview the facility failed to develop a comprehensive infection control
program to decrease the risk of infections and ensure adequate monitoring of infections was completed.
The facility failed to maintain consistent use of isolation precautions for Resident #9 and failed to ensure
dressing changes were completed to reduce the risk of infection for Resident #40 and #110. This affected
three residents (#9, #40 and #110) and had the potential to affect all 126 residents residing in the facility.
Residents Affected - Many
Finding include:
1. Review of the facility monthly infection control logs and quarterly infection control summaries revealed
the total numbers of residents marked as positive for infections for the last four quarters had increased. The
number of residents marked as positive for the first quarter (January to March) of 2019 was 20, the second
quarter (April to June) number was 35, and the third quarter (July to September) for 2019 was 37. There
was no totaled number for the fourth quarter (October to December) of 2019 at the time of the survey.
Review of information provided by the facility revealed an inservice was completed for nurses and state
tested nursing assistants on 09/24/19 and 09/25/19. The outline for the inservice indicated thepaper training
and quiz portion of the inservice had a 30 minute section on infection control-tb (tuberculosis), thirty
minutes for Legionnaires and fifteen minutes dedicated to Needle stick-OSHA (Occupational Safety and
Health Administration). The outline indicated competencies were observed for handwashing and perineal
care for both males and females.
An interview with the infection control nurse, Registered Nurse (RN) #500 and the corporate risk
management nurse/RN #501 on 01/15/20 at 2:10 P.M. revealed RN #500 had just started her duties in her
position within the last three weeks. RN #500 stated she had not had time to review the logs and trends of
the facility infection control tracking. She stated she had not yet completed any inservices for staff, but had
been attempting to review residents and had inventoried infection control supplies at the bedside/doorways
for residents.
An interview with RN #501 on 01/16/20 at 10:30 A.M. revealed she had reviewed the logs and tracking for
the facility. She stated she was unsure of the meaning of the numbers obtained on the quarterly infection
control antibiotic tracking forms. She stated she could not be sure what the former infection control nurse
had counted when obtaining the numbers, which she verified indicated an increase in infections for
residents in the facility. She stated she was also not sure if the census had increased dramatically or if the
infections included in the counts also encompassed hospital acquired infections, facility acquired infections,
residents with colonized infections or all of these
(continued on next page)
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
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
365020
Printed: 05/15/2026
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
365020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
2116 Dover Center Rd
Westlake, OH 44145
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
categories.
Level of Harm - Minimal harm
or potential for actual harm
An interview with medical doctor, (MD) #600, by telephone on 01/16/20 at 3:10 P.M. revealed she was a
consultant at the facility with a speciality in infection control. She stated she had been in frequent contact
with the infection control nurse (RN #505) at the facility in the past but had not received much information
for the last several months.
Residents Affected - Many
An interview with the director of nursing on 01/16/20 at 4:06 P.M. verified RN #505 had retired at the end of
October 2019. She stated another nurse, RN #510 started as the the new infection control nurse soon after
but had resigned her position at the end of December 2019. She stated RN #500 started in the position
approximately three weeks ago. She indicated the facility had been unable to verify some of the tracking
processes used in the past by the nurses who had previously held the position, so could not verify if
numbers had increased or not.
The director of nursing verified the summary of the infections had last been totaled at the end of September
2019, and although infection control logs existed for the rest of 2019, the monthly numbers had not been
calculated or were not accessible at the time of the survey to indicate if infections had continued to increase
or had declined. The director of nursing also verified the facility had conducted an inservice in September
2019, which included teaching and competencies on infection control subjects. She was unable to state if
all nursing staff had completed the inservice or if any audits had been conducted to ensure nursing staff
were adhering to infection control standards.
2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with
diagnoses including dementia and hypertension. She was admitted to Hospice services on 11/01/18.
Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she
was severely cognitively impaired, was dependent of staff for activities of daily living and had a pressure
area.
Review of the medical record revealed a pressure area to the resident's right foot. A wound note dated
01/10/20 revealed the area was a State IV (impaired skin area with exposed bone) to the right proximal
medial first toe which measured 0.5 centimeters by 0.3 centimeters with a depth unable to be determined.
The treatment ordered 10/05/19 revealed the area should be cleaned with normal saline, patted dry and a
betadine moistened gauze applied. The area should be covered with a pad and wrapped with gauze wrap.
An observation of the resident with the wound nurse, RN #407 on 01/16/20 at 8:40 A.M. revealed the
resident was in bed at the time of the observation. RN #407 assembled all equipment on the night stand
and after washing her hands and applying gloves, she used a scissors to cut away the old dressing. She
used a saline moistened gauze to cleanse the area and then applied a gauze pad that had betadine on it.
She covered the area with a pad and wrapped it with a gauze wrap. RN #300 did not change her gloves or
wash her hands during the procedure.
An interview with RN #407 on 01/16/20 at 10:50 A.M. confirmed she did not change gloves during the
procedure. She verified she should have removed her gloves, washed her hands and put on new gloves
after removing the old dressing and cleaning the wound, before applying the new treatment, which she
applied to the area with the same gloved hands with which she had cleaned the area.
Review of the facility undated clean dressing change policy revealed a clean pair of gloves should be
applied then changed after removing the soiled dressing, with a clean pair of gloves put on to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365020
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
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
365020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
2116 Dover Center Rd
Westlake, OH 44145
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
clean the wound and apply the clean dressing.
Level of Harm - Minimal harm
or potential for actual harm
3. Record review revealed Resident #110 was admitted to the facility on [DATE] with diagnoses including
muscle weakness, peripheral vascular disease, Alzheimer's disease and dementia without behavioral
disturbances.
Residents Affected - Many
The care plan dated 12/20/19 included a potential for impaired skin integrity related poor tissue integrity.
The care plan included Resident #110 had a sacrum pressure ulcer, Stage II. The care plan also included
to provide treatment orders per physician orders.
Record review of physician's orders dated 01/10/20 revealed an order to cleanse the sacral wound with
normal saline, pat dry, apply hydrofera blue and cover with a foam dressing every day and as needed.
Observation on 01/16/20 at 9:30 A.M. of sacral wound care for Resident #110 revealed RN #407 entered
Resident #110's room. RN #407 washed her hands then explained the procedure to Resident #110. RN
#407 placed a barrier on the bedside table and placed clean wound dressing supplies on the barrier. RN
#407 then put her gloves on and assisted STNA #408 to position the resident on her left side to provide
wound care. RN #407 removed the old dressing from the sacral wound, laid the old dressing down then
cleansed the wound using a dry gauze and saline solution. RN #407 then took off her gloves and exited the
room. RN #407 gathered supplies from the treatment cart located outside the doorway in the hall. RN #407
then laid the additional supplies on the barrier located on the bedside table. RN #407 put new gloves on
then applied the hydrofera blue to the wound bed then applied the foam dressing.
Interview with RN #407 on 01/16/20 at 9:40 A.M. confirmed she did not dispose of the gloves after
removing the soiled dressing and apply new gloves before cleansing the wound.
Review of the procedure for a clean dressing change, dated 2012 revealed to put on the first pair of
disposable gloves, remove the soiled dressing and discard in a plastic bag, dispose of the gloves in a
plastic bag, put on a second pair of disposable gloves, cleanse the wound.
4. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including
dementia without behavioral disturbance, muscle weakness and shingles. Review of the Minimum Data Set
(MDS) 3.0 assessment dated [DATE] revealed Resident #9 had adequate hearing and vision, her speech
had been clear and had been able to understand verbal content.
Review of the nursing progress notes dated 01/03/20 at 1:00 P.M. revealed Resident #9 had cluster of filled
blisters to the left side of her face/chin and behind her left ear. A call had been placed to Resident #9's
physician and an order was obtained for medication for seven days and Resident #9 was to be placed on
contact precautions.
Review of the written physician's orders, dated 01/03/20 verified an order for contact precautions and a
diagnosis of shingles.
The definition of shingles, according to the Mayo Clinic, revealed shingles was a viral infection that causes
a painful rash. Although shingles can occur anywhere on your body, it most often appears as a single stripe
of blisters that wraps around the left side or the right side of the torso. Shingles is caused by the
varicella-zoster virus, the same virus that causes chicken pox. The
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365020
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
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
365020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
2116 Dover Center Rd
Westlake, OH 44145
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
varicella-zoster virus is contagious, and if you have shingles, you can spread the virus to another person,
which could then, cause them the chicken pox.
Contact precautions refer to infection prevention and control interventions to be used in addition to routine
practices and were intended to prevent transmission of infectious agents which are spread by direct or
indirect contact. Healthcare workers should wear a gown and gloves while in the patient's room.
Review of the care plan for Resident #9 dated 01/06/20 revealed Resident #9 had shingles to the left side
of her face/chin and behind left ear. The intervention for Resident #9 included use contact precautions to
prevent infection.
Observation on 01/13/20 at 11:25 A.M. revealed an isolation cart including isolation gowns and gloves was
located at the entrance of Resident #9's room.
Observation on 01/13/20 at 11:30 A.M. revealed Resident #9 was sitting in a chair in the dining room with
multiple residents and staff members present.
Interview on 01/13/20 at 11:30 A.M. with Licensed Practical Nurse (LPN) #403 revealed if a resident was in
contact precautions, they would be in their room on isolation. LPN #403 verified Resident #9 had been in
the dining room during the interview. LPN #403 verified Resident #9 had been out to the dining room daily
with other residents and staff during the month of January 2020. LPN #9 verified contact precautions had
been ordered by the physician for Resident #9 due to a diagnosis of shingles.
Interview on 01/13/20 with State Tested Nursing Assistant (STNA) #404 revealed Resident #9 has eaten
her meals in the dining room every day and had not eaten anywhere but the dining room with other
residents and staff present for the month of January 2020.
Observation on 01/13/19 at 1:57 P.M. revealed Resident #9 had been sitting in a chair in the dining room.
Interview on 01/16/20 between 1:05 P.M. and 1:10 P.M. with LPN's #405 and #406 confirmed Resident #9
had consumed her meals in the dining room daily with multiple residents and staff present during the month
of January 2020 and while on contact precautions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365020
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the January 16, 2020 survey of LUTHERAN HOME?
This was a inspection survey of LUTHERAN HOME on January 16, 2020. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LUTHERAN HOME on January 16, 2020?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.