Rae-Ann Westlake

In the surveyor’s words

From the most serious findings on record at Rae-Ann Westlake, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 15, 2022

  Based on observation, interview, record review, review of the local police report, witness statements, National Weather Forecast, and facility policy on elopement, the facility failed to provide adequate supervision to prevent one resident (Resident #30) with severe cognitive impairment from eloping from a secured memory care unit. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury and/or death when on 09/04/22 at approximately 7:21 A.M. Resident #30 exited from a secured memory care unit through an exit door requiring a security code into rainy weather. The exit door was within close proximity to a busy two- lane road. The audible alarm on the exit door was activated at 7:21 A.M. and turned off at 7:27 A.M. […]

• Actual harm, isolatedF689Sep 30, 2021

  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 admitted [DATE] with diagnoses including frontal lobe executive function deficit following a cerebral infarction, [CONDITION(S)] with behavioral disturbances, difficulty walking, and history of falls. […]

• No harm, potential for more than minimal, widespreadF812Sep 30, 2021

  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. […]

• No harm, potential for more than minimal, patternF880Nov 13, 2023

  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. Findings include: Review of the medical record for Resident #89 revealed an admitted [DATE], 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. […]

• No harm, potential for more than minimal, patternF695Mar 22, 2023

  Based on observation, interview, record review and policy review, the facility failed to assure that respiratory supplies included an extra trach tube and that the tube was available at the bedside for three residents, Residents #10, #69 and #7, out of 10 residents, Residents #94 #40, #62, #5, #86, #29, and #49, reviewed for` tracheostomy supplies. The facility also failed to assure one resident's ventilator was connected timely to provide oxygen and assure that trach suctioning and physician's orders were followed for one resident, Resident #7, out of three residents, Residents #5, #7, and #62, reviewed for suctioning and physician's orders. The facility census was 96 Findings include: 1. Record review for Resident #10 revealed an admitted [DATE]. […]