Health inspection·June 1, 2023

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. Based on record review, observation, and interview, the facility failed to ensure safety devices were implemented to prevent falls. This affected one (Resident #79) of three residents reviewed for falls. The census was 97. Findings Include: Review of medical record for Resident #79 revealed an admission date of 11/21/21. Diagnoses included Parkinson's disease, morbid obesity, anxiety disorder and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/06/22, revealed Resident #79 had intact cognition. Resident #79 required extensive assistance for bed mobility, transfers, locomotion, and toilet use. Review of the plan of care dated 12/15/21 revealed Resident #79 was at risk for falls due to psychoactive drug use, history of falling, impaired balance, weakness, and Parkinson's disease. Interventions included to ensure call light was in reach and apply a sensor pad to the bed and wheelchair dated 01/26/23. Review of fall assessments dated 02/01/23 and 05/16/23 revealed Resident #79 was at high risk for falls. Review of the incident log revealed Resident #79 had falls on 01/26/23, 04/14/23 and 05/29/23. Review of the progress note dated 01/26/23 timed 7:20 P.M. revealed Resident #79 was found lying on the floor in pain. Resident #79 stated he was going to the bathroom when he fell. Resident #79 was taken to the hospital for evaluation. A new fall intervention to help prevent further falls included a flat sensor alarm to bed and recliner. Review of the progress note dated 04/14/23 at 7:46 A.M. revealed Resident #79 was observed sitting on the floor, no injuries were noted. Staff educated Resident #79 on calling for assistance before getting up. Review of progress note dated 05/29/23 at 1:23 P.M. revealed Resident #79 was observed lying on the floor on his right side. Resident #79 was unable to verbalize what happened. Resident #79 sustained an abrasion to the right elbow. Interview on 05/31/23 at 3:22 P.M. with the wife of Resident #79 revealed Resident #79 had some (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: 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 06/01/2023 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)