Health inspection·February 26, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure fall interventions were in place and failed to ensure a thorough fall investigation was conducted for Resident #15. This affected one (Resident #15) of three residents reviewed for accidents. The facility census was 100.Findings include: Review of the medical record for Resident #15 revealed an admission date of 02/12/25. Diagnoses included vascular dementia, anxiety, osteoarthritis of right shoulder, congestive heart failure, contracture of right hand, dysphagia and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognition. The resident was dependent on staff for bed mobility, transfers, and ambulation. Review of the plan of care dated 01/02/26 revealed Resident #15 was at risk for falls due to dementia with cognitive deficits, anxiety and depression with behaviors and a history of falls. Interventions included nonskid socks at all times, a low bed for safety, bed against the wall, and a fall mat to the floor next to the bed.Review of the fall risk assessment dated [DATE] revealed Resident #15 was at a high risk for falls.Review of physician orders for February 2026 identified orders for a mat to the left side of the bed, bilateral gab bars, and Resident #15 was to be assisted out of bed early in the morning.Review of the nurse's notes dated 02/13/26 at 10:38 P.M. Registered Nurse (RN) #347 entered Resident #15's room to administer evening medications and heard screaming. (Resident #90, who has cognitive impairment who wanders throughout the unit, in and out of other resident's rooms and plays with bed remotes, was in Resident #15's room at the time RN #347 entered the room). Resident #15 was observed lying on the floor in a pool of blood actively bleeding from the right side of her forehead and nose. The resident was assessed, and Emergency Medical Services (EMS) was called. The Director of Nursing (DON), physician and family were notified. The progress note did not state Resident #90 was found in Resident #15's room. (Per interview below with RN #347, Resident #90, who has cognitive impairment who wanders throughout the unit, in and out of other resident's rooms and plays with bed remotes, was in Resident #15's room at the time RN #347 entered the room. Resident #90 was care planned for frequent wandering into other residents' rooms and was combative with redirection).Review of the fall investigation dated 02/13/26 revealed witness statements from the DON and Certified Nursing Assistant (CNA) #252. There were no witness statements from CNA # 280, RN #347 or CNA #285, who were also working at the time of the incident. The risk report listed predisposing environmental factors as other. The risk report stated to describe other. There was no documentation of the other predisposing factors. There was no documentation to indicate if the fall mat was in place. There was no documentation that Resident #90 was found in Resident #15's room at the time of the fall and/or that Resident #90 was care planned for frequent wandering into other residents' rooms and was combative with redirection.Interview on 02/23/26 at 6:34 A.M. RN #349 started on 02/13/26 at 6:45 P.M. and she and CNA #252 put Resident #15 to bed. The bed was in the lowest position with one bolster on the left side due to (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 3 Event ID: 365048 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 365048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Westlake 26520 Center Ridge 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)