Health inspection·October 6, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, facility investigation review, and facility policy review, the facility failed to provide adequate supervision and equipment to ensure all residents remained inside the facility as required. This affected one resident (#61) of three residents reviewed for possible elopement. The census was 60. Findings Include: Resident #61 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, muscle weakness, difficulty walking, lack of coordination, mild cognitive impairment, metabolic encephalopathy, mild cognitive impairment, chronic kidney disease (stage III), atrial fibrillation, atherosclerotic heart disease, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had a severe cognitive impairment. Review of Resident #61 elopement assessment, dated 09/08/23, revealed he scored a zero on the safety assessment, but the facility still deemed him to be an elopement risk based on his cognitive abilities and wandering tendencies. So, at that time, a wanderguard (a bracelet worn by a resident to prevent elopement) was placed on him. Another elopement risk assessment was completed on 09/11/23, which indicated he was a score of two and a risk for elopement. Review of facility Self-Reported Incident (SRI) number 239106, dated 09/12/23, revealed Resident #61's wanderguard was not on his body; it was noticed by Registered Nurse (RN) #101. She did not report that he did not have a wanderguard on to anyone, but the facility staff maintained visual supervision on him. Between 11:15 A.M. and 11:30 A.M., RN #101 indicated to nursing management that she could not find Resident #61. Elopement and missing individual protocol were immediately implemented, which included looking for him off property. He was found approximately a five-minute walk from the facility on the sidewalk; he had left the facility campus. He was returned to the facility with no injuries or health declines, and a wanderguard was placed back on him. Interview with the Administrator on 10/06/23 at 10:40 A.M. and 1:42 P.M. confirmed Resident #61 left the facility campus and was not being supervised as he should. He found out during the investigation that RN #101 knew his wanderguard was not attached to him, she had been attempting to find the nursing supervisor to get another one, and he left the facility prior to her being able to get another one. Interview with RN #101 on 10/06/23 at 11:34 A.M. confirmed she was checking for Resident #61's wanderguard in the morning of 09/12/23 and could not find it. She ensured he was in a safe spot prior to going to look for the nursing supervisor, to get a new wanderguard. She confirmed she did not inform anyone else in the facility that his wanderguard was not on. She attempted multiple times to find the nursing supervisor without success. Each time she would go back to check on Resident #61, and she could not find him the last time. They checked for him around the whole facility and finally found him on the sidewalk near the road. He had no injuries or health declines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366373 If continuation sheet Page 2 of 4 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 366373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Westlake Village 28450 Westlake Village Drive 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility Missing Resident policy, dated September 2023, revealed a missing resident requires immediate associate attention. To assist with the prompt location of a resident, the following procedures should be followed until the resident is found. The supervisor should verify whether or not the resident has signed out. Also, they need to obtain the last time the resident was seen, clothing they were wearing, cognitive and emotional status, height, weight, hair color, and adaptive equipment used, and any distinctive traits of the resident. The staff are to conduct a thorough interior search of the community, notify security personnel, conduct a thorough exterior search of the community, and contact the administrator and director of clinical services. Local law enforcement will also be notified if needed. When the resident is located, the facility will review them for injury or change in condition, complete and incident report, notify the health care provider, and notify the resident's legal representative if necessary. The incident was deemed to be past non-compliance on 09/13/23 due to the following items provided by the facility: • 09/12/23, Resident #61 was fully assessed by facility nursing and deemed to be in good health; there were no injuries or health declines noted. A new wanderguard was placed on his body. • 09/12/23, Director of Nursing (DON) provided education to all nursing staff, including State Tested Nursing Aides (STNA) about the facility's elopement policy and the use of wanderguards for residents. RN #101 was also re-educated and counseled about the importance of communicating when a resident does not have a wanderguard on, and they are ordered to have one. • 09/12/23, facility maintenance staff tested all wanderguard doors and devices; all were working appropriately. • 09/12/23, facility nursing staff reviewed all resident medical records and assessments, deemed there were no other residents who used nor needed a wanderguard at that time. • 09/12/23, extra wanderguards were moved from the storage room to the floor nurse medication carts for easier access. • Starting 09/12/23, the facility-initiated elopement and missing individual drills once per shift, each day for one week (ending on 09/18/23.) Then, starting 09/19/23, the facility initiated the same drill twice a week, for two months. This was being completed as planned based on review of documents on 10/06/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366373 If continuation sheet Page 3 of 4 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 366373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Westlake Village 28450 Westlake Village Drive 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)

F 0689 This deficiency represents non-compliance investigated under Complaint Number OH00146456. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366373 If continuation sheet Page 4 of 4