Health inspection·March 27, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the guardian of transfer to the emergency room. Residents Affected - Few This affected one Resident (Resident #16) of one reviewed for change of condition. The facility census was 84. Findings include: Review of the medical record for the Resident #16 revealed an admission date of 08/17/21. Diagnoses include paranoid schizophrenia, major depressive disorder, anxiety, and chronic obstructive pulmonary disease (COPD). Review of the care plan dated 08/17/22 revealed a plan for alternation in mood and behavior related to diagnoses of paranoid schizophrenia, major depressive disorder, and anxiety. The Resident exhibits behavior of noncompliance with medication, care needs, verbal and physical aggression, explosive outburst over smoking, impulsive and accusatory behaviors, delusional beliefs, and distorted thought pattern. Interventions included to provide activities for increased socialization and participation. Allow resident to make choices and speak in a calm manor. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the Resident #16 had impaired cognition and wandering behaviors. Review of the progress notes dated 03/12/23 at 7:21 P.M. Resident #16 was refusing to leave the smoking room. Resident #16 struck the nurse causing her to fall and then struck her with a close fist in the back of the head. The resident remained in the room and all smoking materials were removed. The Certified Nurse Practitioner (CNP) was notified and gave an order to send to the emergency room for a psychological evaluation. There was no evidence of notification to Resident #16's Guardian. Interview on 03/22/23 at 1:59 P.M. with the Assistant Director of Nursing (ADON) #872 stated the was no evidence of Resident #16's guardian was notified of the behavior or transfer to the emergency room. Interview 03/23/23 2:04 P.M. with Licensed Practical Nurse #809, the nurse on duty at the time of the incident, stated she was not sure if Resident #16's Guardian was contacted for the behavior or transfer to the emergency room. Review of the facility's policy titled Change in Condition, revised December 2016 stated the nurse (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 7 Event ID: 365796 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 03/27/2023 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)