Health inspection·February 8, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Observation and interview on 02/06/24 at 10:44 A.M. with the Director of Nursing (DON) confirmed Resident #152's call light was activated and Resident #152 needed assistance to the bathroom. Observation revealed Resident #152 waited approximately 45 minutes for staff assistance after activating her call light. Follow-up Interview on 02/06/24 at 11:15 A.M. with STNA #817 revealed she was aware Resident #152 needed assistance to the bathroom but she was helping another resident with a shower and Resident #152 had to wait. Event ID: Facility ID: 365115 If continuation sheet Page 2 of 10 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 02/08/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident #6 was receiving an adequate amount of fluids to meet her basic needs. This affected one of one resident reviewed for hydration. The facility census was 110. Residents Affected - Few Findings include: Medical record review revealed Resident #6 was admitted into the facility on [DATE] with diagnoses of unspecified dementia, and disorders of electrolyte and fluid balance. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was severely cognitively impaired and required hands on assistance of two staff persons for completing activities of daily living. Observation on 02/05/24 at 11:22 A.M. revealed Resident #6 sitting in a Broda wheelchair (a wheelchair that provides supportive positioning through a combination of tilt, recline, enhancing patient safety and support) in her room, a Styrofoam cup with a lid and a straw filled with water was sitting on the bedside table placed behind Resident #6, where she was unable to reach it. Observation on 02/06/24 at 10:42 A.M. revealed two Styrofoam cups of water with lids and straws in them sitting on Resident #6 bedside table. Resident #6 was not in her room. Further observation revealed Resident #6 sitting in the dining room in a Broda wheelchair pushed up to a dining room table with no drinks or beverages present. Observation on 02/06/24 at 2:57 P.M. revealed Resident #6 sleeping in her bed with a fall mat lying next to the bed and a bedside table placed next to a wall by the bathroom. There were no beverages present in Resident #6's room. Observation on 02/06/24 at 5:21 P.M. revealed Resident #6 sitting in the dining room in a Broda wheelchair placed at a table, no beverages were present. Observation on 02/07/24 at 8:13 A.M. revealed Resident #6 's room had no beverages present. Observation on 02/07/24 at 8:14 A.M. revealed Resident #6 sitting in a Broda wheelchair in the dining room, with no beverages present. An interview on 02/02/24 at 10:44 A.M., revealed Resident #6 expressed that she was thirsty. Interview on 02/05/24 at 11:11 A.M. with Residents #6's family member revealed when the family member visited Resident #6, there was never any beverages present. The family member said each time she visited Resident #6, she had to get her a cup of water because Resident #6 told the family member she was thirsty each visit. Interview on 02/06/24 at 10:48 A.M. with Licensed Practical Nurse (LPN) #899 revealed she tried to interact with the residents and ask if they were thirsty including Resident #6. LPN #899 further stated activities was also incorporated in helping with providing beverages. Interview on 02/06/24 at 10:53 A.M. with Activities Director (AD) #946 revealed she passed water out to the residents first thing in the morning between 8:00 A.M. to 8:45 A.M. AD #946 said a lot of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 3 of 10 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 02/08/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm times the aides helped serve the residents water that needed assistance. AD #946 further stated the aides should be passing the water and she was not sure why there was no water or beverages in front of Resident #6. AD #946 further stated she just recently got her position, and really, it was the aide's job to make sure the residents had water. Residents Affected - Few Review of Resident #6 fluid intake record from January 2024 to February 2024 revealed: 01/25/24 Resident #6 had a total daily intake of 960 milliliter (ml). 01/26/24 Resident #6 had a total daily intake of 720 ml. 01/27/24 Resident #6 had a total daily intake of 1200 ml. 01/28/24 Resident #6 had a total daily intake of 720 ml. 01/29/24 Resident #6 had a total daily intake of 720 ml. 01/30/24 Resident #6 had a total daily intake of 490 ml. 01/31/24 Resident #6 had a total daily intake of 720 ml. 02/01/24 Resident #6 had a total daily intake of 742 ml. 02/02/24 Resident #6 had a total daily intake of 340 ml. 02/03/24 Resident #6 had a total daily intake of 486 ml. 02/04/24 Resident #6 had a total daily intake of 406 ml. 02/05/24 Resident #6 had a total daily intake of 484 ml. 02/06/24 Resident #6 had a total daily intake of 484 ml. Interview on 02/07/24 at 8:44 A.M. with Licensed Dietician (LD)#857 revealed that minimum fluids were calculated using the current standards of practice. LD #857 explained the current standard of practice was 30 (ml) per kilogram (kg) of body weight. (LD) #857 confirmed using the current standards of practice calculations Resident #6 should be receiving approximately 1200 ml of fluid per day, and verified the contents of the fluid intake records listed above were correct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 4 of 10 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 02/08/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, record review, and interview, the facility failed to ensure residents received appropriate assessment before applying side rails to a bed. This affected one (Resident #44) of five residents reviewed for accident hazards. The total census was 110. Findings include: Observation on 02/05/24 at 9:34 A.M. revealed Resident #44 had a raised side rail on each side of his bed. Record review of Resident #44 revealed he was admitted to the facility 11/14/23 and had diagnoses including lumbar fracture, muscle weakness, and obesity. His current care plan did not include any mention of side rails. Review of his assessments since admission revealed no evidence he was assessed for entrapment risk or appropriate use of bed rails. Interview with the Director of Nursing on 02/07/24 at 12:24 P.M. confirmed the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 5 of 10 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 02/08/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #71 revealed she was admitted [DATE] and had diagnoses including anxiety disorder, dementia, major depressive disorder, and bipolar schizoaffective disorder. Review of a physician order dated 01/31/24 indicated the resident was to receive Paxil (an antidepressant) 10 milligrams for seven days until 02/06/24. Review of the medication administration record revealed the dose was only administered on 01/31/24. Review of Resident #71's progress notes and orders revealed no cancellation or other explanation why the medication was not given the remaining six days. Residents Affected - Few Interview with the Director of Nursing (DON) on 02/07/24 at 12:24 P.M. confirmed the above findings. Follow-up interview with the DON on 02/07/24 at 1:59 P.M. revealed the facility investigation found the order was entered incorrectly into their computer documentation system. Based on record review, medication error/incident report review, order summary review, facility investigation time line review and staff interview the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #101) of one resident reviewed for admission medications and one (Resident #71) of five residents reviewed for unnecessary medications. Findings include: 1. Medical record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, epilepsy and unspecified intellectual disabilities. Review of the Medicare five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was moderately cognitively impaired and required hands on assistance of one staff person for completing activities of daily living (ADLs). Review of the medication error/incident report dated 11/17/23 timed 2:00 P.M. revealed Resident #101 was admitted to the facility on the evening of 11/16/23. On the following day the facility conducted a 24 hour medication audit per its standard policy. Upon completing the audit it was revealed that Resident #101 was sent to the facility from a hospital with another resident's clinical information and medication. At the time of admission nursing staff verified the incorrect medication orders with Resident #101's attending physician. Subsequently Resident #101 received incorrect medication on the evening of 11/16/23 between 5:30 P.M. and 6:00 P.M. These medications included Lisinopril (blood pressure regulating medication) 20 milligrams (mg), Metoprolol Succinate 25 mg (blood pressure regulating medication), Hydralazine (blood pressure regulating medication) 25 mg, insulin 55 units, acetaminophen (pain reliever) 650 mg, Spironolactone (blood pressure/fluid regulating medication) 50 mg, Allopurinol (gout treatment) 300 mg, Amlodipine (blood pressure regulating medication) 25 mg, aspirin (pain reliever) 81 mg and Furosemide (fluid retention treatment) 80 mg. Upon realizing the errors Resident #101 was immediately assessed (no negative finding) and put on hourly checks which also produced no negative findings. Resident #101's attending physician and family were notified of the errors. Correct medication lists were obtained from a local hospital and re-verified with Resident #101's physician. Resident #101's family requested that Resident #101 be sent to a local emergency room for evaluation. Resident #101 left the facility without incident on 11/17/23 at approximately 5:00 P.M. Resident #101 did not return to the facility. Review of an order summary for Resident #101 dated 11/17/23 timed 2:24 P.M. revealed Resident #101's medications included acetaminophen extended release 650 mg twice a day, Allopurinol 300 mg once daily, amlodipine besylate 5 mg once daily and ammonium lactate external lotion 12 percent topically (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 6 of 10 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 02/08/2024 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 0760 twice a day. Level of Harm - Minimal harm or potential for actual harm Review of the facility investigation time line of events dated 01/17/24 revealed on 11/17/23 at 4:20 P.M. Resident #101 was alert and in dining room participating in activities, eating snack and drinking fluids. At 3:07 P.M. Resident 101's vitals included blood pressure 74/59, heart rate 98, respirations 18, and blood sugar 125. The nurse practitioner was notified and ordered Miderine (anti-hypotensive agent). The family declined administration of Miderine and wanted resident sent to emergency room. At 3:20 P.M. emergency services arrived and conducted an assessment of Resident #101. Blood pressure was 118/84. Family talked with paramedics debating on sending to the hospital or continuing to monitor at facility. It was decided to send to hospital. The Director of Nursing (DON) called the daughter on 11/18/23 to check on resident and was told Resident #101 was monitored overnight and given intravenous fluids. Residents Affected - Few Interview with the DON on 02/07/24 at 3:00 P.M. verified that incorrect medications were given to Resident #101 upon her admission to the facility. Review of the policy entitled Administering Medications dated 04/01/19 revealed Medications are administered in accordance with prescriber orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 7 of 10 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 02/08/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure a complete and accurate medical record for Resident #101. This affected one of thirty sampled residents. The facility census was 110. Findings include: Medical record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, epilepsy and unspecified intellectual disabilities. Review of the Medicare five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was moderately cognitively impaired and required hands on assistance of one staff person for completing activities of daily living (ADLs). Review of census records for Resident #101 revealed Resident #101 was discharged to an acute care hospital on [DATE] and did not return to the facility. Review of the electronic and hard chart revealed no information related to the reason Resident #101 was discharged to hospital or condition at the time Resident #101 left the facility to go to the hospital. Interview with the Director of Nursing on 02/07/24 at 3:11 P.M. verified Resident #101's medical record lacked any information related to what lead up to the resident being transferred to the hospital or condition at time of discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 8 of 10 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 02/08/2024 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 0926 Have policies on smoking. 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, staff and resident interview, and policy review, the facility failed to ensure smoking assessments and care plans were completed in a timely manner. This affected two residents (#58 and #152) of two reviewed for smoking. The facility identified twelve residents (#2, #22, #24, #42, #58, #59, #68, #92, #102, #103, #104, #152) who smoked. The facility census was 110. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #152 revealed she was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of anterior wall of bladder, COVID-19, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #152 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time, and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 01/04/24 revealed Resident #152 had no care plan in place for smoking. Review of the progress note dated 01/03/24 at 5:58 P.M. revealed Resident #152 was a smoker. Interview on 02/06/24 at 2:11 P.M. with Registered Nurse (RN) #923 revealed Resident #152 was a smoker upon admission and utilized the designated smoking area daily. RN #923 confirmed there was not a smoking assessment or care plan for Resident #152 in paper chart or electronic medical record. Interview on 02/06/24 at 2:19 P.M. with the Director of Nursing (DON) and the Administrator revealed the Activities Director (AD) #832 was responsible for completing the smoking assessments and was behind in completing them. Follow-up review of the medical record revealed an updated care plan dated 02/06/24 that reflected Resident #152 was a smoker and was safe to smoke with group supervision. Review of the facility document titled Screen for Smoking revealed Resident #152 was screened and assessed for smoking, approximately 29 days after admitting to the facility. Review of the facility document titled Resident Smoking revised 01/30/24, revealed the facility had a policy in place to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Review of the policy revealed residents who smoked would be assessed during the admission process, quarterly and during comprehensive MDS assessments and documented in the resident's care plan. Review of the document revealed the facility did not implement the policy. 2. Review of the medical record for Resident #58 revealed the resident was admitted into the facility on [DATE] with diagnoses including muscle weakness and multiple sclerosis. Review of the annual quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 was cognitively intact, and required maximal/substantial assist for activities of daily living. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 9 of 10 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 02/08/2024 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of the medical record revealed Resident #58 used tobacco products and was assessed to be an independent smoker upon admission on [DATE]. No other smoking assessments were noted in the medical record. Interview on 02/07/24 at 11:30 A.M. with the Executive Director (ED) confirmed Resident #58 had a smoking assessment completed on 09/20/21 when she was admitted to the facility and no other smoking assessments were completed until 02/01/24. Review of the Smoking Policy dated 1/30/24 revealed All residents will be asked about tobacco use during the admission process and during each quarterly or comprehensive MDS assessment process. In addition, Residents who smoke will be further assessed using the Screen for Smoking assessment to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365115 If continuation sheet Page 10 of 10