Health inspection·December 15, 2024

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. Based on observation, staff interview and policy review, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 90. Findings include: Observation of the kitchen area on 12/15/24 between 7:30 A.M. and 8:00 A.M. with Dietary Aides (DA) #600 and #601 revealed the following that was verified at the time of discovery; - A large puddle of water was noted in the facility's dishwasher area. DA #600 explained that a drain to the dishwasher had not been working for some time. DA #600 estimated months and thus created a pool of water in the area. - The sanitizer bucket underneath the dishwasher was open and had a swarm of fruit flies around the lid of the bucket. - A package of bacon was observed to be defrosting in the warming area underneath the steam table. The bacon was noted to be lying in a pool of water on the steam table that was yellow in color and had many noticeable food particles floating in the water. - The left side door of the facility's convection oven was completely stained with grease to the extent you could not see in or out of the door. - The hood suppression system had noticeable buildup of grease and rust. - The area beneath the coffee pots in the kitchen was leaking water from an unknown source. - In the walk-in cooler, a rotten green bell pepper, a package of brown (discolored) celery, three undated peanut butter and jelly sandwiches, and two undated ham and cheese sandwiches were noted. - In the dry storage area, an undated container of cherries and two undated and opened bottles of vanilla extract were noted. Review of the policy entitled Preventing Foodborne Illness-Food Handling dated 07/01/14 revealed food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. This deficiency represents non-compliance investigated under Complaint Number OH00160140. 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: 365845 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 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)