Health inspection·November 13, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, record review, and policy review, the facility failed to maintain infection control practices to prevent the potential spread of COVID-19. This had the potential to affect 16 (#89, #24, #51, #68, #41, #96, #99, #5, #57, #9, #93, #74, #66, #73, #75, and #30) of 16 residents residing on the affected hall. The facility census was 101. Residents Affected - Some Findings include: Review of the medical record for Resident #89 revealed an admission date of 09/12/22, with a current diagnosis of COVID-19. Review of the Annual Minimum Data Set (MDS) for Resident #89 dated 09/06/23, revealed Resident #89 was cognitively intact. Resident #89 required assistants, was not steady, and used a wheelchair for mobility. Review of the Care Plan for Resident #89 dated 11/07/23 revealed Resident #89 had an active COVID-19 diagnosis. Interventions included to maintain infection control per Centers of Disease Control (CDC) Prevention guidelines latest recommendations. Review of the physician orders for Resident #89 dated 11/07/23 revealed droplet precautions due to COVID-19 infection. Interview on 11/13/23 at 3:25 P.M., with Housekeeper #297 revealed Resident #89 was on isolation for COVID-19. Observation and interview beginning on 11/13/23 at 3:26 P.M., revealed Resident #89 had a sign on his door which revealed droplet precautions. Resident #89 had an isolation cart sitting next to the entrance of his doorway. Observation revealed Housekeeper #297 donned Personal Protective Equipment (PPE) to enter and clean Resident #89's room. Housekeeper #297 donned gloves, a gown, and an N95 mask. Housekeeper #297 did not put on goggles or a face shield. Housekeeper #297 entered Resident #89's room with cleaning supplies. Housekeeper #297 began wiping items down in Resident #89's room. Housekeeper #297 then exited the room with her same gown, gloves, and mask, went into the hall where the cleaning cart was located, (in the middle of the hall, outside of Resident #89's room), grabbed additional supplies off the housekeeping cleaning cart, (touching multiple items on the cart) then reentered Resident #89's room to continue cleaning. Within a few minutes, Housekeeper #297 again exited Resident #89's room with her same PPE on, went back to the housekeeping cart and gathered more supplies (after touching several items on the cart) then re-entered Resident #89's room with new supplies. Again, after a few minutes of cleaning in Resident #89's room, Housekeeper #297 again exited Resident #89's room, with the same PPE on (did not remove PPE or wash her hands), went back to the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365115 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 11/13/2023 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)