Health inspection·May 16, 2019

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 develop a plan of care for Resident #42 related to hemodialysis, for Resident #69 related to hospice and for Resident #91 related to a urinary tract infection. This affected one resident (Resident #42) of one resident reviewed for hemodialysis, one resident (Resident #69) of two residents reviewed for hospice services and one resident (Resident #91) of five residents reviewed for urinary tract infections and catheter care. Findings include: 1. Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease, dementia, and renal dialysis dependence. The resident had orders dated 02/26/19 for assessments pre and post dialysis every Tuesday, Thursday, and Saturday. No order was present identifying the time of the procedure or the nurse's role in arranging scheduling and transportation. There was no care plan developed related to the resident's need for dialysis care or the facility staff's responsibilities regarding dialysis were present in his chart. Interview with Resident #42 on 05/13/19 at 9:24 A.M. revealed he received dialysis services outside of the facility. He denied having any concerns with his care related to dialysis, including transportation. Interview with the Director of Nursing (DON) on 05/15/19 at 9:55 A.M. confirmed Resident #42 did not have an active care plan for his dialysis. She said this was due to an error, as the resident was previously off dialysis and it had been restarted, but the facility failed to reactivate his dialysis care plan. 2. Record review revealed Resident #69 had an active order for Hospice services which was initiated on 09/28/18. She was a current resident of the facility at the time of the survey. Record review revealed no evidence a care plan related to Hospice was developed for the actions and care of facility staff to accommodate her Hospice needs. Interview with the DON on 05/16/19 at 11:18 A.M. confirmed Resident #69 did not have an active care plan for Hospice services for the facility. 3. Review of Resident #91's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, restlessness, and agitation. The resident had a physician order dated 05/07/19 for the antibiotic, Cipro 250 milligrams two times a day for seven days for urinary tract infection. Review of the resident's care plans revealed no evidence the facility initiated a care plan for the urinary tract infection. The antibiotic was completed on 05/14/19. During an interview on 05/16/19 at 1:33 P.M., the DON indicated she could not find an acute care plan for Resident #91's urinary tract infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 2 of 5 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 365115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae-Ann Westlake 28303 Detroit Rd 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based observation, record review and interview the facility failed to properly store resident food and maintain sanitary conditions in the nursing unit B refrigerator to prevent contamination and potential food borne illness. This had the potential to affect nine residents (Resident #81, #344, #50, #72, #53, #28, #294, #93 and #32) who resided on unit B. The facility census was 83. Findings include: Observation on 05/13/19 at 9:13 A.M. with Dietary Manager (DM) #500 of nursing unit B refrigerator revealed in the freezer one short, dark colored strand of hair and a nickel sized brown, dried spill near the center of the floor of the freezer compartment. There was also a dried lighter brownish stain/spill along the left side of the bottom shelf, almost in the crease of the floor of the freezer and wall. The refrigerator had a medium sized plastic, clear bowl with a red top with an unidentifiable food in it. The bowl was not labeled or dated. Interview on 05/13/19 at 9:13 A.M. with DM #500 verified the above findings and stated housekeeping staff were responsible for keeping the refrigerators cleaned. Interview on 05/13/19 at 10:10 AM with Housekeeping Director (HD) #501 revealed the nursing unit refrigerators should be cleaned daily in the mornings. The facility identified nine residents, Resident #81, #344, #50, #72, #53, #28, #294, #93 and #32 who resided on unit B. Review of the facility undated policy titled, Resident Food Storage Policy revealed any food brought in for residents shall be stored in the dietary department or nursing stations large appliance refrigerators. Residents foods will be marked with the resident's name and dated. Housekeeping is responsible for keeping the refrigerators cleaned. Outdated food will be disposed of by the food housekeeper. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 3 of 5 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 365115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae-Ann Westlake 28303 Detroit Rd 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure respiratory equipment (nasal cannulas) were stored when not in use in a manner to prevent the potential spread of infection. This affected one resident (Resident #20) of one resident reviewed for oxygen use. The facility identified 15 resident with with oxygen. Residents Affected - Few Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, shortness of breath, and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was severely cognitively impaired, needed extensive assistance with transfers, was frequently incontinent of urine, and used oxygen. Resident #20 had a physician order dated 03/10/19 for oxygen at two liters per minute via nasal cannula continuously to maintain a pulse oximeter of 92 percent for shortness of breath. On 05/13/19 at 8:57 A.M., an observation revealed Resident #20 was not in her room. There was an oxygen concentrator in her room. The oxygen tubing included a nasal cannula. The nasal cannula was laying on the resident's bed. At 9:08 A.M., Resident #20 was observed seated in a wheelchair in the dining room with a portable oxygen. On 05/13/19 at 11:15 A.M., an observation revealed Resident #20 was lying in bed with her eyes closed. She was not wearing oxygen. The oxygen tubing attached to the portable oxygen tank was draped across the seat of the wheelchair. The nasal cannula was positioned on top of the seat of the wheelchair. The tubing attached to the oxygen concentrator was draped across the bed and under the resident. On 05/13/19 at 3:05 P.M., an observation revealed the resident was lying in bed. Both the oxygen concentrator and the portable oxygen were off. The oxygen tubing was draped over the concentrator. The other oxygen tubing was draped over the wheelchair with the nasal cannula positioned on top of the seat of the wheelchair. On 05/15/19 at 10:16 A.M., an observation revealed the oxygen concentrator was off. The oxygen tubing including the nasal cannula were coiled in circular fashion and positioned between the top of the concentrator and the handle. On 05/15/19 at 2:32 P.M., an observation accompanied by Licensed Practical Nurse (LPN) #505 revealed Resident #20 was in bed and not wearing oxygen. One oxygen tubing with nasal cannula was coiled around back handle of wheelchair and the other was coiled in circular fashion and positioned between the top of the oxygen concentrator and the handle. LPN #505 agreed the oxygen tubing was not stored in a sanitary manner. During an interview on 05/15/19 at 3:33 P.M., the director of nursing (DON) indicated the facility has never stored oxygen tubing/nasal cannulas in bags when not in use. She indicated the facility has never had a problem with pneumonia or other infections related to oxygen tubing. The DON revealed the facility's contracted oxygen company has never supplied bags to stored nasal cannulas. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 4 of 5 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 365115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae-Ann Westlake 28303 Detroit Rd 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 0880 Level of Harm - Minimal harm or potential for actual harm Review of the Disposable Respiratory Equipment/Supplies Policy dated 01/17/09 indicated the facility's contracted oxygen company would change and date disposable respiratory equipment/supplies during weekly visits. At the facility's request, the company would supply plastic bags to store the resident's items. Oxygen delivery devices, nasal cannula, oxygen tubing, simple mask, and non-rebreathing mask, were changed weekly or replaced if dropped on the floor or otherwise contaminated, dirty, or occluded. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 5 of 5