Inspection·May 2, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to administer an antibiotic as ordered by the prescriber. This affected one (Resident #8) of three residents receiving antibiotics. The census was 112. Findings include: Review of the medical record for Resident # 8 revealed an admission date of 02/23/23 and a discharge date of 04/13/23. Diagnoses included bipolar disorder, chronic respiratory failure, and paraplegia. Review of the comprehensive Minimum Data Set 3.0 assessment for Resident #8, dated 03/02/23, revealed the resident had intact cognition. Review of physician orders for Resident #8 revealed an order dated 03/30/23 for amoxicillin-pot clavulanate (antibiotic) 875-125 mg every 12 hours for 25 administrations for sepsis. Review of the plan of care dated 03/30/23 revealed Resident #8 was receiving an antibiotic therapy for sepsis. Interventions included administration of medication as ordered by the physician and monitor for nausea, vomiting and or allergic reactions. Review of the Medication Administration Records (MAR) for Resident #8 for March and April 2023 indicated the resident received two doses amoxicillin daily from 04/01/23 to 04/07/23, no doses on 04/08/23 and 04/09/23, and then two daily on 04/10/23, 04/11/23, and one dose on 04/12/23. The total administrations for March and April was 23. Review of nursing progress notes for April 2023, revealed Resident #8 was receiving the amoxicillin daily until 04/07/23. A nurses note dated 04/08/23 at 10:43 P.M. revealed Licensed Practical Nurse (LPN) #212 contacted the pharmacy regarding Resident #8's amoxicillin. Interview on 05/01/23 at 3:20 P.M. with Pharmacy staff revealed 20 tablets of amoxicillin were sent to the facility on [DATE] and five tablets were sent to the facility on [DATE]. Review of the packing slip proof of delivery invoice verified the amount of medication delivered on 03/30/23 and 04/09/23. The amount of amoxicillin sent on 03/30/23 should have lasted until the end of day on 04/08/23. Interview on 05/01/23 at 6:15 P.M. with the Director of Nursing (DON) verified Resident #8 did not receive amoxicillin on 04/08/23 and 04/09/23. The DON could not state why Resident #8 did not receive doses on 04/08/23 and 04/09/23. The DON stated the facility had a starter kit which should always have six tablets of amoxicillin. The DON stated amoxicillin was a common medication used so she could not verify if the starter box had a sufficient amount on 04/08/23 and 04/09/23 to administer to Resident #8. The DON stated staff should have contacted the pharmacy and herself when the amount of amoxicillin was running low. Interview on 05/02/23 at 7:15 A.M. with LPN #212 revealed she contacted the pharmacy on 04/08/23 to refill Resident #8's amoxicillin. LPN #212 verified Resident #8 did not receive his second dose of amoxicillin on 04/08/23. Review of a policy titled, Administering Medications, dated 2018, revealed medication shall be administered in accordance with a valid physician order. The policy had limited documentation directing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 2 of 3 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 365215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Suburban Healthcare and Rehabilitation 20265 Emery Rd North Randall, OH 44128 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 0755 staff to contact the pharmacy when antibiotics were running low. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00142344. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 3 of 3