Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LUTHERAN HOME
WESTLAKE, OH · 40 certified beds · Last Life Safety survey August 24, 2023
CMS Certification Number 365020 · first certified January 1967
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within OH
29 citations — more than 85% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 14 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (April 2025 to April 2026), and past the point by which nine in ten OH facilities have been surveyed. This facility’s last Life Safety survey was August 2023. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 29 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 29 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 29 |
| Median facility in OH | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 29, 2018 | 12 |
| January 16, 2020 | 3 |
| August 24, 2023 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2023-08-24 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2023-08-24 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2023-08-24 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2023-08-24 |
| K-0222 | Add 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. | 2 | 2023-08-24 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2023-08-24 |
| K-0524 | Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | 1 | 2018-11-29 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2018-11-29 |
What the citations cover
- Smoke Deficiencies 11
- Miscellaneous Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 5
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Miscellaneous Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 5 |
| Services Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 24, 2023 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0222 | Add 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. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 12, 2023) |
January 16, 2020 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 21, 2020) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 21, 2020) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (February 21, 2020) |
November 29, 2018 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add 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. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0227 | Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0524 | Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (January 30, 2019) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 30, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.