Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lutheran Home during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate, with 2 errors out of 27 opportunities. One resident received only 1 of 2 ordered vitamin D3 tablets, and another resident received acidophiles with pectin instead of the ordered acidophilus capsule. The DON and LPN confirmed the discrepancies, and the facility policy required use of the five rights of medication administration.
Two residents with indwelling medical devices required EBP, but CNAs did not wear gowns during high-contact care such as dressing, incontinence care, transfers, and device care. One CNA also drained a Foley bag and left the room without hand hygiene, and another left after PEG-related incontinence care without washing hands or using sanitizer. The facility policy required gowns and gloves for these activities.
A resident with multiple complex conditions and a PICC line for IV antibiotics did not receive required weekly dressing changes as ordered. Two LPNs signed off on the dressing changes in the MAR/TAR without actually performing them, resulting in the dressing not being changed since placement. The issue was discovered when the resident attended a follow-up appointment and the soiled, unchanged dressing was noted, leading to removal of the PICC line.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5%, with 2 medication errors identified out of 27 opportunities for a 7.41% error rate. The errors affected 2 of 8 residents observed during medication administration. One resident had an order for vitamin D3 1,000 units, 2 tablets by mouth daily for a supplement, but the LPN administered only 1 tablet during observation. The LPN later confirmed the order required 2 tablets and that only 1 tablet was given. A second resident had an order for acidophilus oral capsule, 1 capsule by mouth daily for gut maintenance, but the LPN administered acidophiles with pectin 100 mg instead. The DON confirmed acidophiles and acidophiles with pectin are different medications, and the LPN confirmed the physician order did not include pectin and that she gave the wrong product. The facility policy on medication administration stated medications were to be administered safely and effectively using the five rights of medication administration.
Failure to Use EBP PPE During High-Contact Care
Penalty
Summary
The facility failed to maintain infection control practices for two residents who required Enhanced Barrier Precautions during high-contact resident care activities. Resident #48 had diagnoses including obstructive and reflux uropathy, retention of urine, and nonrheumatic aortic valve stenosis, was cognitively intact, and required staff assistance for toileting hygiene, lower body dressing, transfers, and bed mobility. He had an indwelling catheter and an order for EBP for catheter care every shift. During observation, CNA #150 provided lower-extremity dressing, repositioning, incontinence care, and transfer assistance without wearing a gown, despite the EBP sign outside the room indicating gowns and gloves were required for dressing, bathing, transferring, hygiene, linen changes, brief changes, and device care. CNA #150 also drained the catheter bag without donning a gown and exited the room with soiled linen without washing hands or using hand sanitizer. Resident #31 had diagnoses including cerebral palsy and gastrostomy status, was cognitively intact, and was dependent on staff for toileting hygiene, dressing, personal hygiene, and chair/bed transfers. The resident was incontinent of bowel and bladder, had impaired upper extremities, and had an order for EBP related to PEG tube care. During observed incontinence care, CNA #184 did not wear a gown while providing care, repositioned the resident multiple times, applied cream to the buttocks, and left the room without washing hands or using hand sanitizer. The facility policy stated that EBP required gown and glove use during high-contact resident care activities for residents with indwelling medical devices, including urinary catheters and feeding tubes.
Failure to Complete PICC Line Dressing Changes as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to ensure that care and services for a peripherally inserted central catheter (PICC) line site were completed as ordered for a resident with multiple complex diagnoses, including Evan's syndrome, systemic lupus erythematosus, hereditary hemolytic anemia, and drug-induced diabetes. The resident was admitted for treatment of a urinary tract infection and required intravenous antibiotics administered through a PICC line in the right upper extremity. Physician orders specified that the PICC line dressing was to be changed weekly on Sundays. Medical record review showed that the Medication Administration Record (MAR) and Treatment Administration Record (TAR) had been signed off by two LPNs for dressing changes on two occasions, but there was no evidence of any dressing changes after those dates, and the order was discontinued later. Progress notes and interviews revealed that the PICC line dressing had not been changed since placement, and the dressing was visibly soiled and dated from the time of insertion when the resident attended a follow-up appointment. The PICC line was removed at the appointment after this was discovered. Staff interviews confirmed that the LPNs had signed off on the dressing changes without actually performing them. One LPN reported not receiving the necessary dressing supplies, while the other believed all assigned dressings had been completed but could not recall specifics. The facility's policy required assessment of the insertion site at each dressing change and labeling of the dressing, but did not specify the frequency of changes. The deficiency was identified through review of records, staff interviews, and facility policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westlake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Westlake | 0.5 mi | ★★★★★ | 15 | 0 |
| Rae-ann Westlake | 0.9 mi | ★★★★★ | 0 | 0 |
| Huntington Woods Care & Rehab Center | 1.4 mi | ★★★★★ | 6 | 0 |
| Rae Ann Suburban | 1.4 mi | ★★★★★ | 5 | 0 |
| Brookdale Westlake Village | 1.5 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.