Health inspection·September 30, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unit. The meal was cabbage rolls, mashed potato, vegetable blend, cake, and various beverages. Registered Nurse (RN) #83 was the nurse on the unit and identified all eleven residents seated in the dining room (Resident's #5, #7, #14, #27, #30, #36, #46, #47, #50, #51 and #53). Dietary Aide (DA) #41 was assisting in the dining room as the trays got delivered from the kitchen at 12:36 P.M. Resident #7 was seated with Resident #47. Resident #7 was the first tray served at 12:38 P.M. At 12:42 P.M. Resident #47 began banging his knuckles of both hands on the table and made slapping hand motions over his head as he watched Resident #7 eat and others around him eating their food. At 12:45 P.M. Resident #47 got his tray. During this observation period the staff proceeded to serve other tables before making sure both residents seated at a table had their food before moving onto the other tables. Interview was conducted on 09/29/21 at 12:50 P.M. with DA #41 who verified she was passing the trays as she pulled them out of the cart and not in order of the tables. When she was asked if she knew who sat at each table, she showed the surveyor each resident's tray card with a table number on the back. When asked why she did not serve one table at a time before moving onto the next she said she served them in the order the trays were placed into the cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 2 of 7 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 09/30/2021 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review and policy review, the facility failed to ensure smoking breaks were provided for Residents #49 and #266. This affected two of three (Resident's #10, #49 and #266) resident's that smoked. The facility census is 65. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, peripheral vascular disease, major depressive disorder, and cirrhosis of liver. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively intact and required assistance of two staff for transfers and one staff for other activities of daily living except for eating. 2. Review of the medical record revealed Resident #266 was admitted on [DATE] with diagnoses including muscle weakness, dysarthria, and anarthria. Review of the quarterly MDS 3.0 assessment revealed it was in progress. Interview and observation on 09/27/21 at 1:15 P.M. revealed Residents (#10, #49 and #266) were smoking in designated smoking area. Resident's #49 and #266 stated that they did not get any smoke breaks on Sunday (09/26/21) because of staffing. Resident #10 stated that she did get smoking breaks because she asked her State Tested Nursing Assistant (STNA) to take her out to smoke. Resident #10 stated the STNA took her out to smoke at 1:30 P.M. and 4:30 P.M., which were not at the designated smoking times but in the designated smoking area. Interview on 09/27/21 at 1:26 P.M. with Social Worker #25 revealed that activities take residents out to smoke but there are no activities person working today, so SW #25 and SW #71 were ensuring the residents got to smoke today, and they both stated they do not work weekends and there had not been an activities director for about a week. Review of the undated facility policy titled; Rae-[NAME] Resident Smoking Policy revealed that smoking will be supervised by a staff member. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 3 of 7 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 09/30/2021 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, record review and interview, the facility failed ensure Resident #34 recieved staff asstistance to shower. Actual Harm occurred when Resident #34 was showering unattended and fell fracturing her shoulder. This affected one (Resident #34) of three residents reviewed for falls. The facility census was 65. Findings include: Review of the medical record for Resident #34 revealed an admission date of 03/06/20 with diagnoses including frontal lobe executive function deficit following a cerebral infarction, vascular dementia with behavioral disturbances, difficulty walking, and history of falls. Review of the fall risk assessments dated 03/15/21, 05/04/21, and 07/29/21 revealed the resident was at high risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/29/21, revealed the resident had impaired cognition. The resident was independent for bed mobility, transfers, and ambulation. The resident required one-staff physical assistance for bathing. Review of the plan of care dated 08/24/21 revealed the resident was at risk for falls due to gait/balance problems, poor communication and comprehension, psychoactive drug use, history of falls, and poor safety awareness. Interventions included to place the call light within reach and encourage the resident to use it, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, maintain a safe environment with even floors free from spills or clutter, and keep personal items within reach. Review of the plan of care dated 09/18/20 revealed the resident had an activities of daily living (ADL) care performance deficit related to confusion. Interventions included to provide physical assist/supervision with bathing dated 04/21/21 and 08/12/21 and a flat sensor pad to the bed and wheelchair dated 09/24/21. Review of physician orders for the past three months identified no fall prevention devices ordered. A lowboy bed and flat sensor pads were implemented on 09/24/21, two days after the fall incident. Review of the nurse's notes dated 09/22/21 at 11:45 A.M. revealed resident was found on her bathroom floor after another resident called out for help. The Director of Nursing, the nurse on duty, and the State Tested Nurse Assistant (STNA) assisted with the occurrence until the paramedics arrived and transported the resident to the hospital. Review of the nurse's notes dated 09/22/21 at 12:30 P.M., revealed the resident was found in her bathroom in the prone (facedown) position with her arm under her. The resident was taking a shower and slipped. Review of the nurse's notes dated 09/22/21 at 9:08 P.M. revealed the facility was informed by the family that the resident had a minor shoulder fracture. Review of the fall investigation dated 09/22/21 revealed Resident #34 was alert to person and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 4 of 7 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 09/30/2021 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 0689 Level of Harm - Actual harm Residents Affected - Few place. The root cause of incident was a wet floor, resident had gait imbalance, impaired memory, and weakness. The report had limited documentation related to interventions that were in place at the time of the incident. Interview on 09/27/21 at 10:27 A.M., MDS Nurse #80 stated that according to the assessments dated 05/04/21 and 07/29/21 the resident required one staff assistance for bathing which means that staff would be assisting the resident and must be physically present during the shower. Interview on 09/29/21 at 10:32 A.M., Restorative Director (RD) #79 stated that no residents were authorized to take a shower without staff regardless of the residents functioning status. Interview on 09/29/21 at 10:40 A.M., Licensed Practical Nurse (LPN) #6 stated that he was at the nurse's desk when he heard the resident call for help. LPN# 6 stated that he told STNA #2 to go to the resident's room. LPN#6 stated that he went down to the resident's room and observed the resident lying on the bathroom floor. LPN#6 stated that Resident #34 would always take showers on her own, but staff would check on her periodically. LPN #6 stated that Resident #34 was not at risk for falls at the time of the incident. Interview on 09/29/21 at 10:49 A.M., STNA #2 stated that she observed water in the hallway in front of the resident's room. STNA #2 stated that no resident called out for help, and she alerted LPN #6 to the incident. The STNA stated that the last time she observed the resident, the resident was lying in bed. STNA #2 stated when she went into the room to check on the resident, the resident was lying face down on the bathroom floor with the lower half of her body resting in the shower. STNA #2 stated that the water was out in the hallway almost reaching the resident room across the hall. Observations at the time of interview revealed that the water had traveled at least 15 feet into the hallway, the hallway had hard floors at time of the incident. STNA #2 stated that the resident's lower body was blocking the drain in the shower. STNA #2 stated that no alarms were sounding at the time of the observation as the resident could have turned off the fall alarm. Further review of the medical record after the interview revealed that the no fall alarms were ordered or implemented until 09/24/21, two days after the fall. Interview on 09/29/21 at 2:53 P.M., the Director of Nursing stated that the resident would be up ad lib (meaning at one's desire) in her room and on the unit. The DON could not state why a resident who is a high fall risk would be able to rise and walk the room or unit without staff assistance. The DON also stated that the resident would be very upset if the facility implemented the sensory pads. This deficiency substantiates Complaint Number OH00113985. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 5 of 7 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 09/30/2021 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interviews and policy review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. This had the potential to affect all 65 residents who received food from the kitchen. The census was 65. Findings include: 1. Initial tour of the kitchen was conducted on 09/27/21 5:58 A.M. to 6:25 A.M. with Registered Dietitian (RD) #44. Above a stainless-steel food preparation table holding the uncovered meat slicer and food processor was a heavily soiled ceiling and side wall of the hood fire suppression unit. The ceiling and side wall had dried on splatters of food crumbs and staining. RD #44 said she believed while processing food some had blown up to the ceiling and had not been cleaned up yet. Next to the hand washing sink were two black plastic polymer dish carts having multiple dividers to separate and stack dishes inside the carts. Both were uncovered, full of dishes and thermal dome covers leaving the clean dishes and domes open for back splashing from the hand sink. The carts presented as unwashed for an extended period, as the bottom had a heavy buildup of whitish-yellow crusting in the crevices and various crumbs and unidentifiable crumb-like particles on the top of the carts and throughout the inside. Within the walk-in cooler were multiple packages of open cheeses either undated or outdated presenting as evidence the cheese was not being rotated and discarded to prevent potential food borne illness sources. An open bag of parmesan cheese within a Ziploc baggie was dated 07/28/21. An opened and partially used block of yellow American cheese was wrapped in Saran Wrap and was undated. An open mozzarella cheese was dated 08/30/21 and open provolone cheese was dated 08/22/21. RD #44 verified the findings and threw out the items saying they usually go through the cooler on Mondays and toss out any outdated food products. When asked if it was acceptable to have open cheese still in the cooler from 07/28/21, 08/22/21 and 08/30/21 she replied the kitchen went by manufacture use by dates if the packages were unopened but once open those items should have been thrown out. The facility provided the surveyor with an undated document titled Policy: Labeling and Discarding of Commercial Food Items. The document stated leftover food should be labeled with the date it was opened and first used and foods need to be discarded within seven days after the commercial product is opened but no longer than the expiration date listed on package. The document gave no instructions for highly perishable foods or time controls for safety for various refrigerated, prepared food items demonstrating a lack of policy guidance to ensure food safety. 2. Observation of the general kitchen environment was conducted on 09/29/2021 from 9:31 A.M. to 9:49 A.M. with Dietary Supervisor (DM) #82 and RD #44. The meat slicer remained uncovered, and the dish carts remained next to the hand sink and remained uncovered. The dish carts were still dirty with crumbs and staining on the bottom and throughout the crevices in the plastic. Gnat traps were observed on the floor behind the three-basin sink with evidence of heavy buildup of black, beige staining and crumbs where the baseboard meets the floor. The uncleanliness of the perimeter of the floor where the baseboards met the floor was noted to be pervasive throughout the kitchen especially behind the cooking ranges and stainless-steel pan tables holding cooking pans. There was a silver bait box approximately eight inches long and four inches wide for catching rodents behind a stainless-steel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 6 of 7 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 09/30/2021 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 preparation table next to the cooking ranges. There was a similar size silver bait box for catching rodents in the dry stock room below a rack of dry breadcrumbs. A heavy collection of crumbs and accumulated buildup of black dirt surrounded the bait box presenting as a concerning opportunity to attract pests to the food supply. The entire perimeter of the dry stock room where the baseboards met the floor was heavily collected with crumbs and dirt build up showing evidence it had gone a long while without proper attention. Residents Affected - Many During this observation DM #82 and RD #44 verified the findings. Both said they had not seen any rodents, but gnats were an ongoing issue. DM #82 said she was in the process of hiring more staff for the kitchen and she expressed she did put out daily assignment sheets for cleaning but did not really keep cleaning lists. Record review was conducted of the facility document titled Rae-[NAME] Dietary Cleaning Log dated 09/05/2021 to 09/30/2021. The log had zones for cleaning listed with the assigned employee position responsible for those zones. It was void for any cleaning assignments specific to the kitchen floor and ceiling. Record review was conducted of the facility document titled State of Ohio Food Inspection Report dated 09/20/2021 and authored by Sanitarian #900. Sanitarian noted the kitchen was found out of compliance for a lack of clean and sanitary food contact surfaces and carts holding plates being stored next to the hand sink. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 7 of 7