Health inspection·October 3, 2018

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dressing before he was to go to an appointment which occurred about 5:30-6:00 A.M. He stated he wanted to smoke and would not come inside .She stated she educated him on the need to change the dressing to decrease the chance of infection; he became upset and moody saying he was sick of getting the dressing changes done; so I put a piece of tape over it to cover it up so that his tendons weren't showing and open to air, to reinforce the dressing he had on which was just hanging; I never got the opportunity to change the dressing, I just covered it up, he was ready to leave for his appointment. Interview with the Director of Nursing (DON) on 10/02/18 at 6:10 P.M. revealed that this incident came up in patient conversation and anytime some resident states something it is investigated. He stated three residents corroborated the story, Resident #113, Resident #11 and Resident #112. The conclusion was that she changed the dressing outside and she was disciplined based on what the residents said 2. The resident council group meeting portion of the annual survey was conducted on 10/02/18 from 3:00 P.M. and 3:27 P.M. Residents #70, #74, #99 and #106 expressed concerns related to staff treating them with respect and dignity. Residents #70, #74, #99 and #106 explained that staff often use vulgar language while in their rooms providing care and throughout the facility hallways. They also noted that both nurses and facility aides were often heard playing vulgar music on their personal electronic devices throughout their work day at the facility. This deficiency substantiates complaint number OH00100310. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 2 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure accurate code status was ordered and correctly documented for two residents, Resident #107, Resident #57. This affected two of four residents reviewed for advanced directives. The facility census was 127. Findings include: 1. Record review revealed Resident #107 was admitted to the facility on [DATE] with the following diagnoses including Dementia with behavioral disturbances, Pick's disease (dementia), psychosis not due to a substance, obesity, and symbolic dysfunctions. This resident had a BIMS (Brief Interview for Mental Status) that could not be assessed on the most recent Minimum Data Set (MDS) assessment dated [DATE]. The resident was independent for most for ADLs (Activities of Daily Living) except for personal hygiene, toileting and dressing, which was extensive assist with one person. On [DATE] at 2:45 P.M. a review of Resident #107's electronic record revealed there were two code statuses. A hard copy in the resident's chart revealed that a do not resuscitate status (DNR) dated [DATE], which indicates that in case or respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life- saving methods are to be used. The electronic record revealed that a full code status was ordered on [DATE] and a DNR dated [DATE]. Interview on [DATE] at 4:10 P.M. with LPN #108 revealed that she wasn't sure what status Resident # 107 sine the electronic chart had both code statuses under the resident's name electronically. 2. Record review revealed Resident #57 was admitted to the facility on [DATE] with the following diagnoses including: Parkinson's disease, paranoid schizophrenia, human immunodeficiency virus (HIV) infection status and anxiety disorder. On [DATE] at 5:00 P.M. a review of Resident #57's electronic record revealed there was no indication of his code status. There was no physician order present to indicate if he was to be a full code or a do not resuscitate status (DNR), which indicates that in case or respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life- saving methods are to be used. On [DATE] at 5:05 P.M. a review of Resident #57's hard chart record revealed no indication of his code status in his record. There were no physician orders, no stickers on the bottom of the front of his chart and no colored pages located anywhere in the chart including under advanced directives tab. Review of the facility policy dated [DATE] titled: Advanced Directives revealed the following: Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advanced directives. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives. Information about whether or not the resident has executed an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 3 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few advanced directive shall be displayed prominently in the medical record. The interdisciplinary team will review annually with the resident his or her advanced directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). The director of nursing services or designee will notify the attending physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care. On [DATE] at 5:30 P.M. an interview along with review of Resident #57's electronic record as well as his hard chart was conducted with licensed practical nurse (LPN)#10 revealing no code status was documented in his record. She stated that there is usually a sticker on the outside of the hard chart on the bottom documenting the code status that a green sticker means full code and a red sticker means DNR status, verifying that neither were present. LPN#10 stated that in an emergency situation staff look in the hard chat under the advanced directive tab that should have a green sheet indicating a full code status or a red sheet indicating a DNR status verifying that neither were present. She stated that staff could then look in the computer electronic record at the physician orders to see what the code status was but when she pulled up his record there was no order. LPN#10 verified that there was no code status ordered for Resident #57 stating that she would not know what to do in the case of an emergency for this resident. She was unsure if she would treat Resident #57 as a full code and perform life saving measures or if she would treat him as a DNR and not perform any life saving measures. On [DATE] at 7:00 P.M. an interview was conducted with the director of nursing (DON) stating the following is the process to indicate code status: when a resident is first admitted to the facility the unit coordinator will go over the advanced directives with the resident and get the advanced directive form signed by the resident if applicable, put it in the orders and put a sticker on the outside of the hard chart indicating the code status, and under the advanced directives tab a green paper is placed indicating full code status or a red paper is placed indicating a DNR status. He stated that if there is no sticker at all the resident is to be treated as a full code, and that the staff should be aware of this. The DON stated that there is no policy for the use of the red and green stickers and papers placed in the resident's record, only that the practice has been going back for years. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 4 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a thorough investigation was completed following a resident's complaint of verbal abuse. This affected one resident (Resident #45) out of three residents reviewed for abuse. The facility census was 127. Residents Affected - Few Findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses of acute/chronic respiratory failure, bipolar disorder, anxiety disorder and viral hepatitis C. Her Minimum Data Set 3.0 (MDS) dated for 09/04/18 showed that this resident was cognitively intact. She needed supervision for most of activities of daily living. Interview with Resident #45 on 09/30/18 at 10:40 A.M. revealed that she felt she was verbally abused by a State Tested Nurse Aide (STNA) who worked in the facility. She stated the aide still sometimes takes care of her. The resident stated that this aide yells at her and bossed her around like she was a child. She further stated that she did inform the Director of Nursing (DON) and he had them both sign a piece of paper. Interview with the DON on 09/30/18 at 2:00 P.M. revealed that he had never heard about this resident being verbally abused but he would investigate it. The DON immediately filed a Self-Reported Incident report (SRI). Review of the SRI #161611 dated 09/30/18 revealed that the DON did talk to the resident on 09/30/18. In the report it stated the DON spoke to the resident regarding the allegation of verbal abuse. The DON then asked the resident if the incident was the complaint of the aide being bossy that happened a couple of months ago; she stated it was. She then told the DON that everything was fine now. The DON further stated in the documentation that he had the aide apologize to the resident back then and both parties stated the incident was resolved. Further review of the SRI file showed no other paperwork or documentation. The DON was asked on 10/03/18 at 10:57 A.M. if he had completed this investigation and he said yes it was complete. When asked about a thorough investigation and further resident and staff interviews regarding this STNA and he stated he did not do that because the incident occurred a couple of months ago. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 5 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for Residents #49 and #103 out of two records reviewed. The facility census was 127. Residents Affected - Few Findings include: 1. Resident #49 was admitted to the facility on [DATE] with diagnosis that included major depressive disorder, psychotic disorder and bipolar disorder. Review of the pre-admission screen and resident review (PASRR) level two evaluation from the state department of mental health dated 07/21/14 revealed Resident #49 had a level two mental illness. Review of section A of the MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?. Social Worker #950 verified the inaccuracies in an interview on 10/01/18 at 3:44 P.M. 2. Resident #103 was admitted to the facility on [DATE] with diagnosis that included paranoid schizophrenia, hypertension and bipolar disorder. Review of the pre-admission screen and resident review (PASRR) level two evaluation from the state department of mental health dated 07/28/16 revealed Resident #103 had a level two mental illness. Review of section A of the MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?. Social Worker #950 verified the inaccuracies in an interview on 10/01/18 at 3:44 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 6 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a care plan was initiated for a resident with Methicillin Resistant Staff Aureus (MRSA) and failed to ensure an infection care plan was updated. This affected two residents (Resident #97 and Resident #223) out of 22 residents whose care plan was reviewed. The facility census was 127. Findings Included: 1. Resident #97 was admitted to the facility on [DATE]. His admitting diagnoses included poisoning by cocaine, necrotizing fasciitis, open wound right lower leg, and open wound left lower leg. The Minimum Data Set 3.0 (MDS) dated [DATE] revealed this resident was cognitively intact. He needed limited assistance of most of the activities of daily living. Review of Resident #97's medical record showed that on 09/06/18 this resident's right leg wound was cultured for bacteria. On 09/12/18 the results of the culture were positive for a bacterium called MRSA. The resident was then placed on isolation precautions. Review of this resident's physician orders there was not an order for isolation precaution due to the MRSA. Review of this resident's care plans revealed he did not have a care plan for the MRSA infection. Interview with the Director of Nursing (DON) on 10/02/18 at 1:40 P.M. verified that this resident did not have a care plan initiated for his MRSA infection. 2. Resident #223 was admitted to this facility on 09/18/18. Her admitting diagnoses included cutaneous abscess of left upper limb, methicillin resistant staphylococcus aureus (MRSA) bipolar disorder and chronic viral hepatitis C. The Minimum Data Set 3.0 (MDS) for this resident dated 09/26/18 revealed this resident was cognitively intact. She was independent of most activities of daily living except for personal hygiene. For personal hygiene she needed limited assistance. Review of this resident's physician orders dated 10/01/18 revealed she was ordered isolation precautions for MRSA in the wound. Reviewed the resident's care plan dated 09/26/18 for IV therapy for need for IV antibiotics for MRSA of left shoulder. Interventions for this care plan included: Assess for signs/symptoms of infection; dressing change as indicated; give IV antibiotics via PICC line and notify physician of any changes of condition. There was no intervention for isolation precautions. Interview with the Assistant Director of Nursing (ADON) on 10/03/18 at 9:30 A.M. verified there was no intervention in the care plan for isolation precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 7 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure a resident's change of condition was assessed and the physician was informed. This affected one resident (Resident #227) out of one resident reviewed for assessments due to change of condition. The facility census was 127. Residents Affected - Few Findings Include: Resident #227 was admitted to this facility on 0924/18. His admitting diagnoses included bacteremia, open wound of lower back, spinal stenosis, respiratory failure and methicillin susceptible staff. Interview with Resident #227 on 09/30/18 at 4:00 P.M. revealed that he has been having numbness and tingling down both legs that started three days ago. He further stated he did inform the nurse who stated that he should tell his physician when he goes for his appointment on 10/03/18. Resident stated that the nurse did not assess his legs or anything. Interview with the physical therapy aide (PTA) #103 on 10/02/18 at 10:30 A.M. revealed that she had seen the resident for physical therapy. She stated he did complain to her about feeling numbness and tingling in both of his legs. This PTA informed the resident that this was natural, and he stated the nurse told him to tell his doctor which she agreed to. Interview with Licensed Practical Nurse (LPN) #104 on 10/03/18 at 9:50 A.M. revealed that the PTA never did inform the resident's nurse about him having the numbness and tingling in his legs, so it was never assessed, and the physician was not contacted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 8 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

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 observations, interview and record review, the facility failed to ensure appropriate procedures were followed to reduce the risk of falls or injury during Hoyer (mechanical) transfers and smoking in a safe manner. This affected one of one (Resident #36) resident reviewed for Hoyer lift transfers and one of two residents (Resident # 91 and Resident #112) for smoking. The facility census was 127. Findings include: 1. On 10/02/18 at 2:30 P.M., review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, quadriplegia, trigeminal, dementia without behavior, dysphagia, and major depressive order. This resident had a BIMS (Brief Interview for Mental Status) of 7 on the most recent Minimum Data Set (MDS) assessment dated [DATE] indicating severe cognitive impairment. The resident was total dependence with two people assist for Activities of Daily Living (ADL)s except for eating. The resident was care planned to be transferred via Hoyer (mechanical) lift. The record review also indicated that on 10/01/17 at approximately 10:30 A.M. that Resident #36 was transferred via Hoyer Lift when the pad ripped, and the resident fell. An interview with family member of Resident #36 on 09/30/18 at 4:45 P.M. revealed the Resident was transferred via Hoyer lift with one person and the strap of the lift broke causing Resident #36 to fall and go to the hospital. An interview with Director of Nursing (DON) revealed on 10/03/18 at 10:55 A.M. revealed Hoyer lift transfers require two State Tested Nurse Aides (STNA)s and STNA #107 was terminated for not following company policy for the incident occurring on 10/01/17. Review of Hoyer lift policy dated 09/20/08 revealed that two staff are to be present at all times with the resident when using lift. 2. On 10/02/18 at 3:00 P.M. review of Resident #91's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, convulsions, alcohol abuse, opioid abuse, dysphagia, major depressive disorder, and schizophrenia bipolar type. This resident had a BIMS of 15 on the admission MDS indicating intact cognition. The resident was extensive assistance with one person for ADLs except eating. The resident was care planned for supervised while smoking and that his cigarettes and lighter will be kept at the nursing station. Observation on 10/02/18 at 1:48 P.M. seen smoking in courtyard unsupervised. Resident stated that he has his cigarettes and lighter on him. This was verified by LPN #104. A review of the smoking policy dated April 2012 revealed that any smoking privileges, restrictions and concerns (for example close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 9 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview the facility failed to ensure medications were stored in a secure manner. This had the potential to affect all 47 residents residing on the 1st floor of building B of the facility . The facility census was 127. Findings Include: Observation of the 1st floor nurses station in the facility's B building on 09/30/18 at 5:47 P.M. noted the door to be unlocked and readily accessible. Inside the nurses station was the facility's medication room which was also noted to be unlocked and the following medication was noted to be unsecured and readily accessible. -four 50 milligram (mg) metoprolol (blood pressure medication) pills. -one 25mg namenda (used to treat Alzheimer's disease) pill. -twenty eight 300mg gabapentin (used to treat seizure disorders) pills. -two 10mg potassium chloride pills. -twelve 50mg atenolol (blood pressure medication) pills. - fifteen 5mg eleoquis (anticoagulant medication) pills. -eighteen 10mg escitalopram (anti-depressant medication) pills. -two 5mg haldol (anti-psychotic medication) pills. -fourteen 0.5 mg haldol pills. -three 5mg trazadone (anti-depressant medication) pills. The facility's Director of Nursing verified the unsecured pills in an interview on 09/30/18 at 5:48 P.M. Review of the facilities undated Storage of Medications policy revealed it is the expectation that compartments containing medications are locked when not in use. The facility identified Residents #5, #9, #16, #17, #33, #41, #47, #57, #58, #60,#77, #80, #94, #96, #110, #111 as cognitively impaired, independently ambulatory and residing on the 1st floor of its B unit building. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 10 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview the facility failed to ensure food was labeled and dated properly. This had the potential to affect 124 of 127 residents whom receive food from the kitchen. The facility identified Residents #16, #38 and #50 as receiving no food by mouth. The facility census was 127. Findings Include: During the initial kitchen tour conducted on 09/30/18 between 8:45 A.M. and 9:07 A.M. with [NAME] #900 the following was noted: 1. An unlabeled and undated canister of chopped ham was noted in the walk-in fridge. 2. An unlabeled and undated canister of ground beef was noted in the walk-in fridge. 3. An unlabeled and undated canister of butter was noted in the walk-in fridge. 4. An undated box containing multiple plastic bags (approximately five) of bone in chicken pieces was noted in the walk-in fridge. 5. An undated bottle of jalapeno peppers was noted in the dry storage area. Cook #900 verified the above findings at the time of observation. Review of the Refrigerated/Frozen Storage policy dated 06/16/18 revealed All foods are labeled with name of the product and the date the product was opened. Review of the Dry Storage policy dated 06/16/18 revealed Food stock is dated on the day of receipt. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 11 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

F 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, the facility failed to ensure resident bed rooms maintained full visual privacy. This affected two (Residents #19 and #90) of two residents reviewed for privacy concerns. The facility census was 127. Residents Affected - Few Findings include: Observation of the room belonging to Residents #19 and #60 on 10/02/18 at 01:46 P.M. revealed no bathroom door was present in the room. The facilities Director of Nursing verified the above findings in an interview on 10/02/18 at 01:49 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 12 of 13 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview the facility failed to ensure its kitchen area was free from pests (flies). This had the potential to affect all residents. The facility identified 124 of 127 residents that receive food from the kitchen. The facility census was 127 Residents Affected - Many Findings Include: During observation of the dinner time tray pass on 09/30/18 between 4:45 P.M. and 5:17 P.M. approximately 10-12 flies were noted swirling around the food serving and preparation areas. Dietary Manager (DM) #910 verified the existence of the flies in an interview on 09/30/18 at 5:18 P.M. DM #910 also noted that he was unaware of the source of flies and stated it was his belief that flies were entering the building through the loading dock but he was unaware of any specific pest control treatment to address the flies in the kitchen. Review of the facilities pest control documentation from 09/20/18, 09/07/18, 08/31/18 and 08/16/18 revealed no evidence of addressing flies in the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 13 of 13