Health inspection·April 10, 2023

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy the facility failed to ensure mood and behavior monitoring for Resident #12 related to the use of Depakote, a mood stabilizer. This affected one resident (#12) out of three residents reviewed for unnecessary medications. The facility census was 93. Residents Affected - Few Findings include: Review of the medical record for the Resident #12 revealed an admission date of 01/13/22. Diagnoses included dementia with behavioral disturbance, diabetes mellitus, mood affective disorder, mild intellectual disabilities, and Down's syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had moderately impaired cognition. No behaviors were identified on the MDS. Resident #12 required limited assistance of one-staff for dressing, toilet use, and personal hygiene. Further review of the MDS assessment revealed Resident #12 received antidepressants daily during the seven-day look back period. Review of the family/resident communication note dated 02/08/23 at 8:07 A.M. revealed Resident #12's sister was made aware and in agreement with increase in Depakote from 250 milligrams (mg) twice a day to 375 mg twice a day. Review of the progress notes dated from 01/06/23 to 04/05/23 revealed no progress notes related to Resident #12 having behaviors. Interviews on 04/07/23 from 7:15 A.M. through 2:00 P.M. with Licensed Practical Nurse (LPN) #201, Registered Nurse (RN) #203, and LPN #204 stated behaviors must be documented in the resident's medical record. Interview on 04/08/23 at 12:44 P.M. with Director of Nursing (DON) #205 and Corporate Administrative Nurse (CAN) #208 revealed behaviors for residents were documented in the progress notes and verified there was no documented evidence of behaviors for Resident #12 to justify the increase in Depakote. Review of the facility policy titled Dementia - Clinical Protocol, dated 11/2018, revealed the interdisciplinary team (IDT) will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise and the physician and staff will review the effectiveness and complications of medications used to try to enhance cognition and manage behavioral and psychiatric symptoms and will adjust, stop, or change such medications as indicated. (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: 365115 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 365115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae-Ann Westlake 28303 Detroit 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)