Inspection·November 24, 2025

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, review of facility education in-service, review of a disciplinary action form, and staff interview, the facility failed to ensure care and services for a peripherally inserted central catheter (PICC) line site were completed as ordered. This affected one resident (#70) of three residents reviewed for intravenous (IV) access. The facility census was 66.Findings include: Review of the medical record for Resident #70 revealed an admission date of 08/21/25 and discharge date of 09/13/25. Diagnoses included Evan's syndrome (an autoimmune disorder where the immune system destroys its own blood cells), systemic lupus erythematosus, hereditary hemolytic anemia, long term use of antibiotics, and drug or chemical induced diabetes mellitus with hyperglycemia.Review of the admission assessment dated [DATE] revealed Resident #70 admitted to the facility from the hospital for urinary tract infection (UTI) and was being treated with antibiotics (ATB). It was noted Resident #70 had PICC line to right upper extremity (RUE).Review of Resident #70's physician order dated 08/23/25 revealed an order to change the RUE PICC line site dressing every week on Sundays. An additional order dated 08/23/25 noted Resident #70 had an upcoming follow-up appointment with a hematology center on 09/05/25 at 11:30 A.M. for a scheduled treatment. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2025 revealed Licensed Practical Nurse (LPN) #800 had signed off for the dressing change for Resident #70's PICC line site dressing on 08/24/25 and Agency LPN #801 had signed off the dressing change for Resident #70's PICC dressing on 08/31/25.Review of the MAR and TAR for September 2025 revealed no evidence of any dressing changes to Resident #70's RUE PICC line site. The order was discontinued on 09/07/25.Review of Resident #70's progress notes revealed a note dated 09/05/25 which indicated Resident #70's PICC site had been discontinued. Review of a progress note dated 09/08/25 revealed Resident #70 was seen by Nurse Practitioner (NP) #809. The note referenced Resident #70 had completed IV antibiotic treatment on 08/31/25. NP #809 noted Resident #70's PICC line was placed on 08/20/25. It was noted Resident #70 had a follow-up appointment with hematology on 09/05/25 and her PICC line was removed at the appointment. The note indicated the PICC line was removed as it was discovered the PICC line dressing was never changed since placement. Blood cultures were drawn and the PICC line was removed at the hematology appointment.Interview on 11/20/25 at 1:06 P.M. with Infusion Center Nurse #810 revealed on 09/05/25, Resident #70's PICC line dressing was noted to be very visibly soiled and was dated for 08/20/25. Infusion Center Nurse #810 stated Resident #70's PICC line was removed at the appointment on 09/05/25.Interview on 11/24/25 at 8:26 A.M. with the Director of Nursing (DON) revealed education was completed for all nurses on PICC line site care. The DON indicated LPN #800 was written up for signing off on Resident #70's PICC line dressing that she did not complete. The DON stated she was not working at this facility during this time.Interview on 11/24/25 at 9:49 A.M. with Assistant Director of Nursing (ADON) revealed she was the facility's infection preventionist. The ADON reported Resident #70 was Residents Affected - Few (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 2 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 11/24/2025 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)