Health inspection·February 29, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review the facility failed to ensure an allegation of staff to resident abuse was reported to the state agency as required. This affected one resident (#80) of three residents reviewed for abuse. The facility census was 102. Findings Include: Resident #80 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, dementia with other behavioral disturbance, generalized anxiety disorder, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had moderately impaired cognition and was independent for ambulation. Interview on 02/29/24 at 10:00 A.M. with Human Resources Director (HR) #204 revealed that there was an incident this past weekend that involved Resident #80 and a dietary staff member. HR #204 stated that he is investigating the incident of Dietary Aide (DA) #214 holding a resident's wrist, but it wasn't abuse. Interview on 02/29/24 at 11:06 A.M. with Director of Nursing (DON) revealed that she heard about an incident on Monday (02/26/24) where a dietary employee grabbed Resident #80's wrist after Resident #80 asked for something. We are investigating it. Interview on 02/29/24 at 12:37 P.M. with Registered Nurse (RN) #208 revealed that he learned about the incident on Monday (02/26/24) morning. He stated that he was not on call over the weekend but heard there was an altercation between an employee and Resident #80 when Resident #80 wanted something specific from the kitchen. Resident #80 went to the kitchen and an employee put her hand on Resident #80's wrist. On Monday around 1:00 P.M., Resident #80 was walking near the office, and he assessed Resident #80's arms, there were no marks, and Resident #80 did not complain of pain. Review of the soft file for the incident on 02/25/24 revealed that there were three statements from staff regarding the incident. Review of the unsigned, undated statement with the name of [NAME] #213 printed on top with an incident dated 02/25/24 revealed that on Sunday (02/25/24) afternoon while on tray line, DA #214 stated that Resident #80 bothered her several times while delivering food carts to the units. [NAME] #213 told DA #214 to give her whatever she wants because it's Resident #80's residence and she was allowed. Page 1 of 2 365048 365048 02/29/2024 Life Care Center of Westlake 26520 Center Ridge Rd Westlake, OH 44145

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DA #214 stated to [NAME] #213 that she didn't care what Resident #80 wanted because Resident #80 comes to the kitchen a lot. DA #214 stated that Resident #80 was bothering her for stuff and stated that Resident #80 was acting aggressive, and that DA #214 would not fight Resident #80 because she would go to jail for homicide. Review of the statement dated 02/28/24 at 10:31 A.M. from Licensed Practical Nurse (LPN) #217 revealed that he did not have any employee or resident come to him about abuse. Review of the statement dated 02/27/24 from [NAME] #216 revealed that Resident #80 was asking for a popsicle and DA #214 told Resident #80 that she would have to wait because we were busy. [NAME] #216 got a popsicle for Resident #80. [NAME] #216 wrote that he did not see anyone hit anyone but saw Resident #80 raise her hand to DA #214 and overheard DA #214 saying, I am not playing with her. I'm not her child, and she better not put her hands on me. Interview on 02/29/24 at 1:10 P.M. with the Administrator revealed that he was made aware of the incident on Monday by HR #204. The Administrator stated that through their investigation, it was a customer service issue and not abuse, so it did not have to be reported. The Administrator stated that the dietary employee was suspended pending the outcome of the investigation, and HR #204 is still investigating. The Administrator verified that the investigation included three statements. Interview on 02/29/24 at 1:40 P.M. with Dietary Manager #211 revealed that she was informed about the incident on Monday (02/26/24) around 8:30 A.M. She heard from [NAME] #213 and DA #215 that Resident #80 came to the dietary door and asked DA #214 for a popsicle. Resident #80 put her hand up and DA #214 held Resident #80's wrist to keep her from hitting her. Resident #80 had been asking for popsicles a lot because her teeth were pulled several weeks ago. DM #211 stated that she told her staff that residents should not be denied anything if it was available. DM #211 stated that she reported to HR #204 because the Administrator was in a meeting. DM #211 stated that HR #204 told her to take DA #214 off the schedule until the investigation is completed. Review of the Ohio Department of Health's Gateway system revealed no self-reported incident related to the allegation of DA #214 holding Resident #80's arms. Review of the undated facility policy titled, Protection of Residents: Reducing the Treat of Abuse and Neglect, revealed that the facility must ensure all alleged violations involving abuse are reported immediately for serious injury and 24-hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and other officials including to the state agency. This deficiency represents non-compliance investigated under Complaint Number OH00150994. 365048 Page 2 of 2