Westpark Healthcare Campus

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet