Health inspection·August 20, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure Resident #43's allegation of staff-to-resident physical abuse was timely reported to the State Agency. This affected one resident (#43) out of three residents reviewed for abuse. The facility census was 89.Findings include: Review of Resident #43's medical record revealed an admission date of 06/04/24 and diagnoses included cardiac arrest, schizophrenia, and cognitive communication deficit.Review of Resident #43's care plan dated 12/05/24 included Resident #43 had the potential to demonstrate verbally abusive behaviors related to poor impulse control. Resident #43 would verbalize understanding of the need to control verbally abusive behavior. Interventions included to assess Resident #43's coping skills and support system; assess Resident #43's understanding of the situation and allow time for Resident #43 to express self and feelings towards the situation.Review of Resident #43's Minimum Data Set annual assessment dated [DATE] revealed Resident #43 had moderate cognitive impairment. Resident #43 had no impairment of her upper and lower extremities and did not use a cane or walker. Resident #43 required setup or clean-up assistance with toileting hygiene and oral hygiene, and supervision or touching assistance with bathing and dressing. Resident #43 had no physical or verbal behavioral symptoms over the seven day look back period. Resident #43 rejected evaluation or care four to six days over the seven day look back period.Review of Resident #43's medical record including progress notes and assessments dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not reveal evidence of Resident #43's statement that Certified Nursing Assistant (CNA) #203 grabbed her cheek and pinched it during the smoke break on 08/04/25 at 7:00 P.M. There was no evidence Resident #43's cheek was evaluated for pain, injury, bruising and swelling. There was no evidence Resident #43's physician, nurse practitioner, or family member was notified of the allegation. There was no evidence vital signs were checked or that Resident #43 was monitored after the allegation was made. Review of Resident #43's progress notes dated 08/04/25 at 7:00 P.M. through 08/11/25 at 11:20 A.M. did not reveal evidence Resident #43 was evaluated by a physician or nurse practitioner.Review of the facility Self Reported Incident Form dated 08/05/25 at 11:36 A.M. revealed on 08/04/25 at 7:00 P.M., an incident occurred in the smoke room. On 08/05/25, in the morning, Resident #43 stated to Unit Manager (UM) #200 that CNA #203 grabbed and pinched her cheek last night. CNA #203 was not on duty when the allegation was made. UM #200 noted no injury to Resident #43's jaw or cheek. The Administrator was notified of the allegation. The Administrator notified NP #201 immediately and no new orders were given. A message was left on Family Member (FM) #202's phone and CNA #203 was interviewed. Residents #20 and #28 were in the smoke room with Resident #43 and CNA #203 at the time of the incident and were interviewed. Other staff were interviewed. One resident (Resident #20) stated CNA #203 put her hand near Resident #43's face and one resident (Resident #28) did not remember anything happened. Resident #43 was monitored by UM #200 and the nursing staff during the week. FM #202 called the facility Page 1 of 13 365796 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 08/06/25 and stated she was not notified of the allegation. The Administrator called FM #202 and informed her a call was placed the morning of 08/05/25 and UM #200 left a message as well. FM #202 stated she did not receive the messages. FM #202 was informed of Resident #43's allegation, informed CNA #203 was suspended pending an investigation, and that no injury was noted by UM #200 or the charge nurse. The Administrator visited with Resident #43 on 08/07/25, discussed the investigation and CNA #203 was off the schedule during the investigation. Resident #43 stated several times she apologized to CNA #203 for calling her an expletive, and stated CNA #203 pinched her cheek. There was no edema or bruising noted to Resident #43's cheek. Resident #43 stated she was okay with CNA #203 continuing to work her unit and was happy she was suspended for a few days. As a result of the investigation, the facility educated CNA #203 for how to better handle a situation when she was called a name by a resident. Education was previously scheduled for 08/11/25 by the facility psychiatry service and topics included resident behaviors, mental illness, and de-escalation techniques. On 08/08/25, the Administrator requested the in-service also included how to manage reactions when being yelled at by residents or being called names. CNA #203 attended the in-service. CNA #203 was given a break from the behavioral unit and was scheduled to work on other nursing units. Psychiatric NP was notified of the incident and was asked to evaluate Resident #43 on 08/11/25. Due to no evidence that CNA #203 touched Resident #43, no injury was noted, and there was no intention to harm Resident #43, the facility could not determine if abuse occurred. Abuse was not suspected.Review of Resident #43's Allegation of Abuse or Neglect Checklist dated 08/05/25 included on 08/05/25 at 9:30 A.M., the staff member accused was removed from direct resident contact immediately. On 08/05/25 in the morning (time was not identified), UM #200 took Resident #43's statement. On 08/05/25 at 9:30 A.M., Nurse Practitioner (NP) #201 was notified and at approximately 11:00 A.M., Family Member (FM) #202 was notified via message of the allegation. On 08/06/25, the Administrator spoke with FM #202 regarding the allegation. Review of a witness statement dated 08/05/25 (no time identified) included while passing breakfast trays UM #200 walked into Resident #43's room to set up her breakfast tray when Resident #43 stated there was a problem. Resident #43 stated CNA #203 grabbed her left cheek and pinched it the night before. Resident #43 stated she called CNA #203 an expletive and that was why she believed CNA #203 grabbed her cheek. Resident #43 stated she felt safe in the facility, and had no visible marks or bruises noted at the time. Resident #43 stated the pain went away after awhile.Review of a witness phone interview on 08/05/25 (no time identified) included the Administrator immediately interviewed CNA #203 after the Administrator was informed of the situation. CNA #203 stated after dinner she was in the smoke room, she lit Resident #43's cigarette, and when she lit her cigarette Resident #43 said You are a [expletive]. CNA #203 stated she pointed her finger at Resident #43 and asked her why would you call me that. CNA #203 stated Resident #43 did not say anything else but apologized to her for calling her an expletive and they shared a hug. When asked if she touched Resident #43, CNA #203 stated, I never touched her, I did not grab her cheek. Interview on 08/05/25 at 9:00 A.M. of Resident #43 by Social Services Designee (SSD) #204 included Resident #43 was sitting on a chair in UM #200's office and appeared calm and carefree. Resident #43 was swinging her legs and appeared happy. Resident #43 engaged in conversation and made eye contact. Resident #43 stated she call CNA #203 an expletive while in the smoking room. Resident #43 stated after she called CNA #203 an expletive, CNA #203 reached across and grabbed her cheek. Resident #43 stated it was brief, then she exited the smoking room. Resident #43 stated she felt safe in the facility and her cheek was no longer sore.Review of Resident #20's Witness Statement Form dated 08/05/25 included while they were in the smoke room Resident #43 called CNA #203 an expletive, and CNA #203 walked up to Resident #43, put her hand next 365796 Page 2 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to her cheek and CNA #203 asked Resident #43 what she called her. Resident #43 hollered out that her cheek hurt. Resident #43 confirmed she called CNA #203 an expletive.Review of Licensed Practical Nurse (LPN) #205's Witness Statement Form dated 08/05/25 (no time identified) included last night (08/04/25) she was administering medications to the residents and Resident #43 asked her for Tylenol. When asked about her pain, Resident #43 stated my mouth and face hurts me. Resident #43 stated CNA #203 grabbed at her mouth after she called her an expletive. Resident #43 stated she squeezed it really hard and asked if her face was swollen. Resident #43 stated give me lots of Tylenol, she was going to tell UM #200 about the incident, and she can't do that to me. On 08/04/25 at 9:30 P.M., Resident #43 repeated what she said multiple times while her medication was administered. LPN #205 wrote a note that Resident #43 had minimal swelling of the left lower cheek and mouth area with a question mark next to it. Review of LPN #205's Teachable Moment via phone dated 08/05/25 in the morning (no time was identified) included LPN #205 did not immediately report a concern reported to her by Resident #43 of a staff member (CNA #203) pinching her cheek. All staff must immediately report any allegation of abuse, neglect, misappropriation or exploitation to the Administrator or Supervisor. LPN #205 voiced understanding.Review of an email sent on 08/07/25 at 4:44 P.M. from the Administrator to the Administrator. There was a handwritten note next to a picture of a phone call to FM #202 stating a call was placed to Resident #43's daughter (FM #202) and a message was left for her to call the facility. The picture had FM #202's phone number showing and the call was placed Tuesday, but there was no date showing Tuesday was 08/05/25.Review of a witness statement dated 08/07/25 (time not identified) written by UM #200 included a message was left for FM #202 to update her on a recent altercation on 08/07/25 as a statement was made FM #202 was not notified. The Administrator placed a call on 08/05/25 to inform FM #202 with no response. Awaiting response for second attempt.Interview on 08/19/25 at 9:26 A.M. of Family Member (FM) #202 revealed she was not notified about Resident #43's allegation that CNA #203 pinched her cheek on 08/04/25. FM #202 stated her Aunt visited Resident #43 on 08/05/25 and Resident #43 told her that CNA #203 hit her in the face. FM #202 indicated Resident #202's face was red, swollen, and pictures were taken. FM #202 stated the Administrator called her after she reported the incident to the Stage Agency and told her they did not observe swelling, bruising, or redness on Resident #43's face. FM #202 indicated CNA #203 was suspended pending the outcome of the investigation, but she was still working at the facility. FM #202 stated she requested that CNA #203 not take care of Resident #43 going forward, and Resident #43 was not comfortable with CNA #203 providing her care. FM #202 stated she told a nurse to call Resident #43's physician or nurse practitioner to make sure they were aware the incident happened.Interview on 08/19/25 at 12:19 P.M. of the Administrator revealed on 08/05/25, UM #200 was passing breakfast trays and Resident #43 told her CNA #203 pinched her cheek. UM #200 reported the allegation to the Administrator at about 9:30 A.M. LPN #205 was in the facility, was interviewed by UM #200, wrote a witness statement then left the facility. The Administrator stated she did not read LPN #205's witness statement until later, and after reading it she called LPN #205 and asked her if she reported the allegation to anyone. LPN #205 stated she told UM #200 about it on 08/05/25. The Administrator stated she told LPN #205 she should have immediately notified the Administrator or a Supervisor when she found out about the incident. The Administrator stated she had a long phone conversation with CNA #203 about the incident, and CNA #203 stated she did not touch Resident #43. CNA #203 was suspended pending the outcome of the investigation. The Administrator stated on 08/05/25, she did not see Resident #43, but UM #200 and SSD #204 interviewed her and did not observe an injury. Resident #43 continued with the story that CNA #203 pinched her cheek. Resident #43 was evaluated on 08/11/25 by a psychiatric nurse practitioner. The 365796 Page 3 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator stated she called FM #202 on 08/05/25, left a message, but forgot to call her back on 08/06/25. On 08/06/25, the Receptionist told the Administrator that FM #202 was upset about Resident #43's cheek getting pinched, and FM #202 stated she was not notified this happened. The Administrator stated when she observed Resident #43 on 08/07/25, she did not have an injury. The Administrator stated she could not prove if CNA #203 pinched or did not pinch Resident #43's cheek. The Administrator indicated LPN #205 was off sick from work and when she returned on 08/22/25 she was escalating the Teachable Moment to a Verbal Write Up because she did not report the incident immediately.Interview on 08/19/25 at 12:55 P.M. of Resident #20 revealed she was in the smoking room on 08/04/25 at 7:00 P.M. when the incident between Resident #43 and CNA #203 occurred. Resident #20 stated Resident #43 asked CNA #203 for another cigarette and CNA #203 told her she already gave her one. Resident #43 called CNA #203 an expletive, CNA #203 touched Resident #43's face, it was real quick, then Resident #43 said it hurt and questioned why did you do that? Resident #20 stated it was a touch and Resident #43 cried out and said it hurt. Resident #20 stated from the angle she was sitting she could not see exactly what CNA #203 did to Resident #43 to cause her to yell out. Resident #20 indicated after this happened they were arguing and Resident #43 said she was going to get CNA #203 for hurting her and at that point CNA #203 walked away. Resident #43 did not say anything after CNA #203 walked away.Observation on 08/19/25 at 1:05 P.M. of Resident #43 revealed she was sitting by a table in the common area. Resident #43's left cheek was not swollen, bruised, or reddened. Resident #43 stated she was arguing with CNA #203 and CNA #203 pinched her face and twisted her fingers while pinching it. Resident #43 stated CNA #203 should not have done that, but they had no further issues the rest of the evening. Resident #43 stated she was not afraid, but she did not like CNA #203 and did not want her around her. Resident #43 stated if CNA #203 did it again she was going to punch her and then I will have a problem for protecting myself.Telephone interview on 08/19/25 at 3:07 P.M. of CNA #203 revealed on 08/04/25 at 7:00 P.M. it was smoke time, she shared the cigarettes and Resident #43 was sitting by the door and called her an expletive. CNA #203 stated she did not touch Resident #43's face, but put her hand up and said why would you call me an expletive? CNA #203 indicated Resident #43 apologized for calling her an expletive and she took care of her the rest of the night without issues. CNA #203 stated when she returned to work she was not assigned to the secured third floor where Resident #43 resided and had not cared for her since.Interview on 08/20/25 at 8:47 A.M. of the Administrator revealed when there was an abuse allegation she expected nurses to first protect the resident and make sure the resident was safe. After assuring resident safety the Administrator expected nurses to notify her immediately, assess the resident, and notify the residents nurse practitioner or physician of the allegation of abuse. The Administrator stated statements should be taken from the staff before they left the facility and families and social services should be notified. The Administrator confirmed Resident #43's medical record dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not have documentation regarding the abuse allegation. The Administrator confirmed Resident #43's medical record did not have evidence Resident #43 was assessed for face or cheek pain after the allegation of abuse was made. The Administrator confirmed Resident #43's medical record did not contain evidence FM #202 or Resident #43's physician or nurse practitioner was notified of the allegation that CNA #203 pinched her cheek. The Administrator stated the facility SRI contained all the documentation regarding the allegation of abuse and an assessment of Resident #43 for injury.Interview on 08/20/25 at 9:19 A.M. of UM #200 revealed on 08/05/25 she walked into Resident #43's room with her breakfast tray and Resident #43 stated we have a problem. Resident #43 told her on 08/04/24 during the 7:00 P.M. smoke break she called CNA #203 an expletive and CNA #203 touched her cheek and 365796 Page 4 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pinched her. UM #200 confirmed she did not see swelling, bruising on Resident #43's cheek and she denied pain. UM #200 stated she asked LPN #205 if she was aware of Resident #43's allegation that CNA #203 pinched her cheek. LPN #205 stated she knew about the allegation, and Resident #43 told her CNA #203 grabbed her face, but she did not see an injury. After speaking with LPN #205, UM #200 told the Administrator about the allegation and interviewed Resident #43 with SSD #204. Resident #43's story stayed the same, and throughout the day it changed from she pinched my cheek to she tried to kill me. UM #200 stated an investigation was completed and education given to the nurses about reporting abuse allegations immediately. UM #200 confirmed she wrote a witness statement, but did not document it in Resident #43's electronic medical record. UM #200 stated CNA #203 had not worked on the third floor secured unit since the incident occurred on 08/04/25.Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation, and Mistreatment Policy dated 11/28/16 included it was the facility policy to investigate all allegations, suspicions, and incidents of abuse, neglect, exploitation, mistreatment, and the misappropriation of resident property, and report the results of any such investigation as required by law. Documentation in the nurses' notes should include the results of the resident's ROM (range of motion), body assessment, vital signs, the notification of the physician (if necessary) and the responsible party and treatment provided. The facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately but not later than two hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Number 2585793. 365796 Page 5 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

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 observation, interview, record review, and facility policy review, the facility failed to ensure a comprehensive investigation for Resident #43's allegation of staff-to-resident physical abuse was completed. This affected one resident (#43) out of three residents reviewed for abuse. The facility census was 89.Findings include: Review of Resident #43's medical record revealed an admission date of 06/04/24 and diagnoses included cardiac arrest, schizophrenia, and cognitive communication deficit.Review of Resident #43's care plan dated 12/05/24 included Resident #43 had the potential to demonstrate verbally abusive behaviors related to poor impulse control. Resident #43 would verbalize understanding of the need to control verbally abusive behavior. Interventions included to assess Resident #43's coping skills and support system; assess Resident #43's understanding of the situation and allow time for Resident #43 to express self and feelings towards the situation.Review of Resident #43's Minimum Data Set annual assessment dated [DATE] revealed Resident #43 had moderate cognitive impairment. Resident #43 had no impairment of her upper and lower extremities and did not use a cane or walker. Resident #43 required setup or clean-up assistance with toileting hygiene and oral hygiene, and supervision or touching assistance with bathing and dressing. Resident #43 had no physical or verbal behavioral symptoms over the seven day look back period. Resident #43 rejected evaluation or care four to six days over the seven day look back period.Review of Resident #43's medical record including progress notes and assessments dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not reveal evidence of Resident #43's statement that Certified Nursing Assistant (CNA) #203 grabbed her cheek and pinched it during the smoke break on 08/04/25 at 7:00 P.M. There was no evidence Resident #43's cheek was evaluated for pain, injury, bruising and swelling. There was no evidence Resident #43's physician, nurse practitioner, or family member was notified of the allegation. There was no evidence vital signs were checked or that Resident #43 was monitored after the allegation was made. Review of Resident #43's progress notes dated 08/04/25 at 7:00 P.M. through 08/11/25 at 11:20 A.M. did not reveal evidence Resident #43 was evaluated by a physician or nurse practitioner.Review of the facility Self Reported Incident Form dated 08/05/25 at 11:36 A.M. revealed on 08/04/25 at 7:00 P.M., an incident occurred in the smoke room. On 08/05/25, in the morning, Resident #43 stated to Unit Manager (UM) #200 that CNA #203 grabbed and pinched her cheek last night. CNA #203 was not on duty when the allegation was made. UM #200 noted no injury to Resident #43's jaw or cheek. The Administrator was notified of the allegation. The Administrator notified NP #201 immediately and no new orders were given. A message was left on Family Member (FM) #202's phone and CNA #203 was interviewed. Residents #20 and #28 were in the smoke room with Resident #43 and CNA #203 at the time of the incident and were interviewed. Other staff were interviewed. One resident (Resident #20) stated CNA #203 put her hand near Resident #43's face and one resident (Resident #28) did not remember anything happened. Resident #43 was monitored by UM #200 and the nursing staff during the week. FM #202 called the facility on 08/06/25 and stated she was not notified of the allegation. The Administrator called FM #202 and informed her a call was placed the morning of 08/05/25 and UM #200 left a message as well. FM #202 stated she did not receive the messages. FM #202 was informed of Resident #43's allegation, informed CNA #203 was suspended pending an investigation, and that no injury was noted by UM #200 or the charge nurse. The Administrator visited with Resident #43 on 08/07/25, discussed the investigation and CNA #203 was off the schedule during the investigation. Resident #43 stated several times she apologized to CNA #203 for calling her an expletive, and stated CNA #203 pinched her cheek. There was no edema or bruising noted to Resident #43's cheek. Resident #43 stated she was okay with CNA #203 continuing to work her unit and was happy she was suspended for a Residents Affected - Few 365796 Page 6 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few few days. As a result of the investigation, the facility educated CNA #203 for how to better handle a situation when she was called a name by a resident. Education was previously scheduled for 08/11/25 by the facility psychiatry service and topics included resident behaviors, mental illness, and de-escalation techniques. On 08/08/25, the Administrator requested the in-service also included how to manage reactions when being yelled at by residents or being called names. CNA #203 attended the in-service. CNA #203 was given a break from the behavioral unit and was scheduled to work on other nursing units. Psychiatric NP was notified of the incident and was asked to evaluate Resident #43 on 08/11/25. Due to no evidence that CNA #203 touched Resident #43, no injury was noted, and there was no intention to harm Resident #43, the facility could not determine if abuse occurred. Abuse was not suspected.Review of Resident #43's Allegation of Abuse or Neglect Checklist dated 08/05/25 included on 08/05/25 at 9:30 A.M., the staff member accused was removed from direct resident contact immediately. On 08/05/25 in the morning (time was not identified), UM #200 took Resident #43's statement. On 08/05/25 at 9:30 A.M., Nurse Practitioner (NP) #201 was notified and at approximately 11:00 A.M., Family Member (FM) #202 was notified via message of the allegation. On 08/06/25, the Administrator spoke with FM #202 regarding the allegation. Review of a witness statement dated 08/05/25 (no time identified) included while passing breakfast trays UM #200 walked into Resident #43's room to set up her breakfast tray when Resident #43 stated there was a problem. Resident #43 stated CNA #203 grabbed her left cheek and pinched it the night before. Resident #43 stated she called CNA #203 an expletive and that was why she believed CNA #203 grabbed her cheek. Resident #43 stated she felt safe in the facility, and had no visible marks or bruises noted at the time. Resident #43 stated the pain went away after awhile.Review of a witness phone interview on 08/05/25 (no time identified) included the Administrator immediately interviewed CNA #203 after the Administrator was informed of the situation. CNA #203 stated after dinner she was in the smoke room, she lit Resident #43's cigarette, and when she lit her cigarette Resident #43 said You are a [expletive]. CNA #203 stated she pointed her finger at Resident #43 and asked her why would you call me that. CNA #203 stated Resident #43 did not say anything else but apologized to her for calling her an expletive and they shared a hug. When asked if she touched Resident #43, CNA #203 stated, I never touched her, I did not grab her cheek. Interview on 08/05/25 at 9:00 A.M. of Resident #43 by Social Services Designee (SSD) #204 included Resident #43 was sitting on a chair in UM #200's office and appeared calm and carefree. Resident #43 was swinging her legs and appeared happy. Resident #43 engaged in conversation and made eye contact. Resident #43 stated she call CNA #203 an expletive while in the smoking room. Resident #43 stated after she called CNA #203 an expletive, CNA #203 reached across and grabbed her cheek. Resident #43 stated it was brief, then she exited the smoking room. Resident #43 stated she felt safe in the facility and her cheek was no longer sore.Review of Resident #20's Witness Statement Form dated 08/05/25 included while they were in the smoke room Resident #43 called CNA #203 an expletive, and CNA #203 walked up to Resident #43, put her hand next to her cheek and CNA #203 asked Resident #43 what she called her. Resident #43 hollered out that her cheek hurt. Resident #43 confirmed she called CNA #203 an expletive.Review of Licensed Practical Nurse (LPN) #205's Witness Statement Form dated 08/05/25 (no time identified) included last night (08/04/25) she was administering medications to the residents and Resident #43 asked her for Tylenol. When asked about her pain, Resident #43 stated my mouth and face hurts me. Resident #43 stated CNA #203 grabbed at her mouth after she called her an expletive. Resident #43 stated she squeezed it really hard and asked if her face was swollen. Resident #43 stated give me lots of Tylenol, she was going to tell UM #200 about the incident, and she can't do that to me. On 08/04/25 at 9:30 P.M., Resident #43 repeated what she said multiple times while her 365796 Page 7 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication was administered. LPN #205 wrote a note that Resident #43 had minimal swelling of the left lower cheek and mouth area with a question mark next to it. Review of LPN #205's Teachable Moment via phone dated 08/05/25 in the morning (no time was identified) included LPN #205 did not immediately report a concern reported to her by Resident #43 of a staff member (CNA #203) pinching her cheek. All staff must immediately report any allegation of abuse, neglect, misappropriation or exploitation to the Administrator or Supervisor. LPN #205 voiced understanding.Review of an email sent on 08/07/25 at 4:44 P.M. from the Administrator to the Administrator. There was a handwritten note next to a picture of a phone call to FM #202 stating a call was placed to Resident #43's daughter (FM #202) and a message was left for her to call the facility. The picture had FM #202's phone number showing and the call was placed Tuesday, but there was no date showing Tuesday was 08/05/25.Review of a witness statement dated 08/07/25 (time not identified) written by UM #200 included a message was left for FM #202 to update her on a recent altercation on 08/07/25 as a statement was made FM #202 was not notified. The Administrator placed a call on 08/05/25 to inform FM #202 with no response. Awaiting response for second attempt.Interview on 08/19/25 at 9:26 A.M. of Family Member (FM) #202 revealed she was not notified about Resident #43's allegation that CNA #203 pinched her cheek on 08/04/25. FM #202 stated her Aunt visited Resident #43 on 08/05/25 and Resident #43 told her that CNA #203 hit her in the face. FM #202 indicated Resident #202's face was red, swollen, and pictures were taken. FM #202 stated the Administrator called her after she reported the incident to the Stage Agency and told her they did not observe swelling, bruising, or redness on Resident #43's face. FM #202 indicated CNA #203 was suspended pending the outcome of the investigation, but she was still working at the facility. FM #202 stated she requested that CNA #203 not take care of Resident #43 going forward, and Resident #43 was not comfortable with CNA #203 providing her care. FM #202 stated she told a nurse to call Resident #43's physician or nurse practitioner to make sure they were aware the incident happened.Interview on 08/19/25 at 12:19 P.M. of the Administrator revealed on 08/05/25, UM #200 was passing breakfast trays and Resident #43 told her CNA #203 pinched her cheek. UM #200 reported the allegation to the Administrator at about 9:30 A.M. LPN #205 was in the facility, was interviewed by UM #200, wrote a witness statement then left the facility. The Administrator stated she did not read LPN #205's witness statement until later, and after reading it she called LPN #205 and asked her if she reported the allegation to anyone. LPN #205 stated she told UM #200 about it on 08/05/25. The Administrator stated she told LPN #205 she should have immediately notified the Administrator or a Supervisor when she found out about the incident. The Administrator stated she had a long phone conversation with CNA #203 about the incident, and CNA #203 stated she did not touch Resident #43. CNA #203 was suspended pending the outcome of the investigation. The Administrator stated on 08/05/25, she did not see Resident #43, but UM #200 and SSD #204 interviewed her and did not observe an injury. Resident #43 continued with the story that CNA #203 pinched her cheek. Resident #43 was evaluated on 08/11/25 by a psychiatric nurse practitioner. The Administrator stated she called FM #202 on 08/05/25, left a message, but forgot to call her back on 08/06/25. On 08/06/25, the Receptionist told the Administrator that FM #202 was upset about Resident #43's cheek getting pinched, and FM #202 stated she was not notified this happened. The Administrator stated when she observed Resident #43 on 08/07/25, she did not have an injury. The Administrator stated she could not prove if CNA #203 pinched or did not pinch Resident #43's cheek. The Administrator indicated LPN #205 was off sick from work and when she returned on 08/22/25 she was escalating the Teachable Moment to a Verbal Write Up because she did not report the incident immediately.Interview on 08/19/25 at 12:55 P.M. of Resident #20 revealed she was in the smoking room on 08/04/25 at 7:00 P.M. when the incident between Resident #43 and CNA 365796 Page 8 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #203 occurred. Resident #20 stated Resident #43 asked CNA #203 for another cigarette and CNA #203 told her she already gave her one. Resident #43 called CNA #203 an expletive, CNA #203 touched Resident #43's face, it was real quick, then Resident #43 said it hurt and questioned why did you do that? Resident #20 stated it was a touch and Resident #43 cried out and said it hurt. Resident #20 stated from the angle she was sitting she could not see exactly what CNA #203 did to Resident #43 to cause her to yell out. Resident #20 indicated after this happened they were arguing and Resident #43 said she was going to get CNA #203 for hurting her and at that point CNA #203 walked away. Resident #43 did not say anything after CNA #203 walked away.Observation on 08/19/25 at 1:05 P.M. of Resident #43 revealed she was sitting by a table in the common area. Resident #43's left cheek was not swollen, bruised, or reddened. Resident #43 stated she was arguing with CNA #203 and CNA #203 pinched her face and twisted her fingers while pinching it. Resident #43 stated CNA #203 should not have done that, but they had no further issues the rest of the evening. Resident #43 stated she was not afraid, but she did not like CNA #203 and did not want her around her. Resident #43 stated if CNA #203 did it again she was going to punch her and then I will have a problem for protecting myself.Telephone interview on 08/19/25 at 3:07 P.M. of CNA #203 revealed on 08/04/25 at 7:00 P.M. it was smoke time, she shared the cigarettes and Resident #43 was sitting by the door and called her an expletive. CNA #203 stated she did not touch Resident #43's face, but put her hand up and said why would you call me an expletive? CNA #203 indicated Resident #43 apologized for calling her an expletive and she took care of her the rest of the night without issues. CNA #203 stated when she returned to work she was not assigned to the secured third floor where Resident #43 resided and had not cared for her since.Interview on 08/20/25 at 8:47 A.M. of the Administrator revealed when there was an abuse allegation she expected nurses to first protect the resident and make sure the resident was safe. After assuring resident safety the Administrator expected nurses to notify her immediately, assess the resident, and notify the residents nurse practitioner or physician of the allegation of abuse. The Administrator stated statements should be taken from the staff before they left the facility and families and social services should be notified. The Administrator confirmed Resident #43's medical record dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not have documentation regarding the abuse allegation. The Administrator confirmed Resident #43's medical record did not have evidence Resident #43 was assessed for face or cheek pain after the allegation of abuse was made. The Administrator confirmed Resident #43's medical record did not contain evidence FM #202 or Resident #43's physician or nurse practitioner was notified of the allegation that CNA #203 pinched her cheek. The Administrator stated the facility SRI contained all the documentation regarding the allegation of abuse and an assessment of Resident #43 for injury.Interview on 08/20/25 at 9:19 A.M. of UM #200 revealed on 08/05/25 she walked into Resident #43's room with her breakfast tray and Resident #43 stated we have a problem. Resident #43 told her on 08/04/24 during the 7:00 P.M. smoke break she called CNA #203 an expletive and CNA #203 touched her cheek and pinched her. UM #200 confirmed she did not see swelling, bruising on Resident #43's cheek and she denied pain. UM #200 stated she asked LPN #205 if she was aware of Resident #43's allegation that CNA #203 pinched her cheek. LPN #205 stated she knew about the allegation, and Resident #43 told her CNA #203 grabbed her face, but she did not see an injury. After speaking with LPN #205, UM #200 told the Administrator about the allegation and interviewed Resident #43 with SSD #204. Resident #43's story stayed the same, and throughout the day it changed from she pinched my cheek to she tried to kill me. UM #200 stated an investigation was completed and education given to the nurses about reporting abuse allegations immediately. UM #200 confirmed she wrote a witness statement, but did not document it in Resident #43's electronic medical record. UM #200 365796 Page 9 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated CNA #203 had not worked on the third floor secured unit since the incident occurred on 08/04/25.Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation, and Mistreatment Policy dated 11/28/16 included it was the facility policy to investigate all allegations, suspicions, and incidents of abuse, neglect, exploitation, mistreatment, and the misappropriation of resident property, and report the results of any such investigation as required by law. Documentation in the nurses' notes should include the results of the resident's ROM (range of motion), body assessment, vital signs, the notification of the physician (if necessary) and the responsible party and treatment provided. The facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately but not later than two hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Number 2585793. 365796 Page 10 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #43 was administered medication per physician order and that medication was accurately documented in the medical record. This affected one resident (#43) out of one resident reviewed for medication administration. The facility census was 89.Findings include: Review of Resident #43's medical record revealed an admission date of 06/04/24 and diagnoses included cardiac arrest, schizophrenia, and cognitive communication deficit.Review of Resident #43's care plan dated 08/21/24 included Resident #43 had the potential for pain related to falls. Resident #43 would voice adequate relief of pain or the ability to cope with incompletely-relieved pain through the review date. Interventions included to administer analgesia medications per orders, give one-half hour before treatments or care, anticipate the need for pain relief, and respond timely to any complaint of pain.Review of Resident #43's Minimum Data Set annual assessment dated [DATE] revealed Resident #43 had moderate cognitive impairment. Resident #43 had no impairment of her upper and lower extremities and did not use a cane or walker. Resident #43 required setup or clean-up assistance with toileting hygiene and oral hygiene, and supervision or touching assistance with bathing and dressing. Resident #43 had no physical or verbal behavioral symptoms over the seven day look back period. Resident #43 rejected evaluation or care four to six days over the seven day look back period.Review of Resident #43's physician orders dated 08/01/25 through 08/20/25 did not reveal orders for Tylenol (an over the counter mild pain reliever and fever reducer).Review of Resident #43's Medication Administration Record (MAR) dated 08/01/25 through 08/20/25 did not reveal Resident #43 was administered Tylenol for pain. Further review did not reveal non-pharmacological interventions were attempted for pain.Review of Resident #43's medical record including progress notes and assessments dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not reveal evidence of Resident #43's statement that CNA #203 grabbed her cheek and pinched it during the smoke break on 08/04/25 at 7:00 P.M. There was no evidence Resident #43's cheek was evaluated for pain, injury, bruising and swelling. There was no evidence Resident #43's physician, nurse practitioner, or family member was notified of the allegation. There was no evidence vital signs were checked or Resident #43 was monitored after the allegation was made. Review of the facility Self Reported Incident Form dated 08/05/25 at 11:36 A.M. revealed on 08/04/25 at 7:00 P.M., an incident occurred in the smoke room. On 08/05/25, in the morning, Resident #43 stated to Unit Manager (UM) #200 that CNA #203 grabbed and pinched her cheek last night. CNA #203 was not on duty when the allegation was made. UM #200 noted no injury to Resident #43's jaw or cheek. The Administrator was notified of the allegation. The Administrator notified NP #201 immediately and no new orders were given. A message was left on Family Member (FM) #202's phone and CNA #203 was interviewed. Residents #20 and #28 were in the smoke room with Resident #43 and CNA #203 at the time of the incident and were interviewed. Other staff were interviewed. One resident (Resident #20) stated CNA #203 put her hand near Resident #43's face and one resident (Resident #28) did not remember anything happened. Resident #43 was monitored by UM #200 and the nursing staff during the week. FM #202 called the facility on 08/06/25 and stated she was not notified of the allegation. The Administrator called FM #202 and informed her a call was placed the morning of 08/05/25 and UM #200 left a message as well. FM #202 stated she did not receive the messages. FM #202 was informed of Resident #43's allegation, informed CNA #203 was suspended pending an investigation, and that no injury was noted by UM #200 or the charge nurse. The Administrator visited with Resident #43 on 08/07/25, discussed the investigation and CNA #203 was off the schedule during the investigation. Resident #43 stated several times she apologized to CNA 365796 Page 11 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #203 for calling her an expletive, and stated CNA #203 pinched her cheek. There was no edema or bruising noted to Resident #43's cheek. Resident #43 stated she was okay with CNA #203 continuing to work her unit and was happy she was suspended for a few days. As a result of the investigation, the facility educated CNA #203 for how to better handle a situation when she was called a name by a resident. Education was previously scheduled for 08/11/25 by the facility psychiatry service and topics included resident behaviors, mental illness, and de-escalation techniques. On 08/08/25, the Administrator requested the in-service also included how to manage reactions when being yelled at by residents or being called names. CNA #203 attended the in-service. CNA #203 was given a break from the behavioral unit and was scheduled to work on other nursing units. Psychiatric NP was notified of the incident and was asked to evaluate Resident #43 on 08/11/25. Due to no evidence that CNA #203 touched Resident #43, no injury was noted, and there was no intention to harm Resident #43, the facility could not determine if abuse occurred. Abuse was not suspected.Review of a witness statement dated 08/05/25 (no time identified) included while passing breakfast trays UM #200 walked into Resident #43's room to set up her breakfast tray when Resident #43 stated there was a problem. Resident #43 stated CNA #203 grabbed her left cheek and pinched it the night before. Resident #43 stated she called CNA #203 an expletive and that was why she believed CNA #203 grabbed her cheek. Resident #43 stated she felt safe in the facility, and had no visible marks or bruises noted at the time. Resident #43 stated the pain went away after awhile.Review of a witness phone interview on 08/05/25 (no time identified) included the Administrator immediately interviewed CNA #203 after the Administrator was informed of the situation. CNA #203 stated after dinner she was in the smoke room, she lit Resident #43's cigarette, and when she lit her cigarette Resident #43 said You are a [expletive]. CNA #203 stated she pointed her finger at Resident #43 and asked her why would you call me that. CNA #203 stated Resident #43 did not say anything else but apologized to her for calling her an expletive and they shared a hug. When asked if she touched Resident #43, CNA #203 stated, I never touched her, I did not grab her cheek. Interview on 08/05/25 at 9:00 A.M. of Resident #43 by Social Services Designee (SSD) #204 included Resident #43 was sitting on a chair in UM #200's office and appeared calm and carefree. Resident #43 was swinging her legs and appeared happy. Resident #43 engaged in conversation and made eye contact. Resident #43 stated she call CNA #203 an expletive while in the smoking room. Resident #43 stated after she called CNA #203 an expletive, CNA #203 reached across and grabbed her cheek. Resident #43 stated it was brief, then she exited the smoking room. Resident #43 stated she felt safe in the facility and her cheek was no longer sore.Review of Resident #20's Witness Statement Form dated 08/05/25 included while they were in the smoke room Resident #43 called CNA #203 an expletive, and CNA #203 walked up to Resident #43, put her hand next to her cheek and CNA #203 asked Resident #43 what she called her. Resident #43 hollered out that her cheek hurt. Resident #43 confirmed she called CNA #203 an expletive.Review of Licensed Practical Nurse (LPN) #205's Witness Statement Form dated 08/05/25 (no time identified) included last night (08/04/25) she was administering medications to the residents and Resident #43 asked her for Tylenol. When asked about her pain, Resident #43 stated my mouth and face hurts me. Resident #43 stated CNA #203 grabbed at her mouth after she called her an expletive. Resident #43 stated she squeezed it really hard and asked if her face was swollen. Resident #43 stated give me lots of Tylenol, she was going to tell UM #200 about the incident, and she can't do that to me. On 08/04/25 at 9:30 P.M., Resident #43 repeated what she said multiple times while her medication was administered. LPN #205 wrote a note that Resident #43 had minimal swelling of the left lower cheek and mouth area with a question mark next to it. Interview on 08/19/25 at 11:29 A.M. of the Director of Nursing (DON) confirmed Resident #43's MAR dated 08/04/25 through 08/20/25 365796 Page 12 of 13 365796 08/20/2025 Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not reveal evidence LPN #205 administered Tylenol for complaints of cheek and face pain. The DON confirmed LPN #205 did not document a pain level for Resident #43's complaints of face and cheek pain from being pinched.Interview on 08/19/25 at 12:55 P.M. of Resident #20 revealed she was in the smoking room on 08/04/25 at 7:00 P.M. when the incident between Resident #43 and CNA #203 occurred. Resident #20 stated Resident #43 asked CNA #203 for another cigarette and CNA #203 told her she already gave her one. Resident #43 called CNA #203 an expletive, CNA #203 touched Resident #43's face, it was real quick, then Resident #43 said it hurt and questioned why did you do that? Resident #20 stated it was a touch and Resident #43 cried out and said it hurt. Resident #20 stated from the angle she was sitting she could not see exactly what CNA #203 did to Resident #43 to cause her to yell out. Resident #20 indicated after this happened they were arguing and Resident #43 said she was going to get CNA #203 for hurting her and at that point CNA #203 walked away. Resident #43 did not say anything after CNA #203 walked away.Observation on 08/19/25 at 1:05 P.M. of Resident #43 revealed she was sitting by a table in the common area. Resident #43's left cheek was not swollen, bruised or reddened. Resident #43 stated she was arguing with CNA #203 and CNA #203 pinched her face and twisted her fingers while pinching it. Resident #43 stated CNA #203 should not have done that, but they had no further issues the rest of the evening. Resident #43 stated she was not afraid, but she did not like CNA #203 and did not want her around her. Resident #43 stated if CNA #203 did it again she was going to punch her and then I will have a problem for protecting myself.Interview on 08/20/25 at 8:47 A.M. of the Administrator revealed when there was an abuse allegation she expected nurses to first protect the resident and make sure the resident was safe. After assuring resident safety the Administrator expected nurses to notify her immediately, assess the resident, and notify the residents Nurse Practitioner or Physician of the allegation of abuse. The Administrator stated statements should be taken from the staff before they left the facility and families and social services should be notified. The Administrator confirmed Resident #43's medical record dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not have documentation regarding the abuse allegation. The Administrator confirmed Resident #43's medical record did not have evidence Resident #43 was assessed for pain, injury or was monitored after the allegation of abuse was made. The Administrator confirmed Resident #43's medical record did not contain evidence FM #202 or Resident #43's Physician or Nurse Practitioner was notified of the allegation that CNA #203 pinched her cheek. The Administrator stated the facility SRI contained all the documentation regarding the allegation of abuse and an assessment of Resident #43 for injury.Interview on 08/20/25 at 11:02 A.M. of the DON revealed Resident #43 did not have a physician order for Tylenol. The DON stated LPN #205 should have contacted Resident #43's physician when she complained of pain on 08/04/25. The DON confirmed there was no reconciliation that Resident #43 received Tylenol as stated in the witness statement.This deficiency represents non-compliance investigated under Complaint Number 2585793. 365796 Page 13 of 13