Inspection·September 5, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few closed fracture of the right distal femur. The history indicated the resident was brought into the emergency medical center (EMS) following a fall. The resident was in her wheelchair when she fell and hit her head on the seat. A physical examination revealed bilateral lower extremity weakness. Imaging revealed a subsegmental pulmonary embolism of the right lower lobe, a nondisplaced fracture of the left humeral head and bilateral distal femur fractures. The resident went to the operating room (OR) with orthopedics for an open reduction internal fixation (ORIF) of the bilateral distal femurs with reported estimated blood loss (EBL) of 600 ml (milliliters). The documentation confirmed on 08/18/23, Resident #56's surgical repairs included ORIF of the bilateral distal femurs and a closed reduction of the left humerus. Review of Resident #56's progress note dated 08/25/23 at 2:44 P.M. revealed the resident was re-admitted to the facility from the hospital with a discharge plan for an evaluation after rehabilitation. Interview on 09/05/23 at 6:52 A.M. with Resident #56 revealed she was on the transport bus and Central Supply/Driver #805 was driving. She stated he missed his exit and braked hard causing her to fall out of her wheelchair. She stated she tried to brace herself but she fell to the floor of the transport bus. She stated Central Supply/Driver #805 asked her if she would like to go back to the facility or to the emergency room and she told him to call the facility and ask them what they wanted to do. She stated she was transported to the emergency room and had to have surgery on her bilateral lower legs. Interview on 09/05/23 at 7:00 A.M. with Central Supply/Driver #805 revealed he transported Resident #56 to a doctor's office approximately three weeks ago. Central Supply/Driver #805 indicated Resident #56 did not like the safety harness to prevent her from coming out of her wheelchair during the drive and had requested that he not use the safety harness, so he did not put the harness on her. He stated all people have different body sizes and he felt maybe this was why she did not want the harness. During the interview, he confirmed he was required to use the harness for resident safety and stated he had to apply the brakes (of the van) because there were a lot of brake lights in front of him. He stated STNA #814 was in the back with the resident and then the resident slid out of the chair and onto the floor. He stated he pulled over and went to the nearest parking lot and called EMS. He stated approximately fifteen minutes later, the EMS squad arrived and transported the resident to the hospital. He denied Resident #56 had lost consciousness. Central Supply/Driver #805 revealed following the incident, he was educated on the appropriate procedures when transporting residents including using the safety harness and he had denied any accidents or incidents had happened in the past. However, Central Supply/Driver #805 then indicated he had transported another resident recently without the safety harness but stated he could not remember that resident's name. Interview on 09/05/23 at 10:25 A.M. with the Administrator revealed he was aware Central Supply/Driver #805 did not use the safety harness when transporting Resident #56 to an appointment and the resident sustained fractures requiring surgical intervention. He stated Central Supply/Driver #805 received a final written warning and was educated on the appropriate procedures when transporting residents. Interview on 09/05/23 at 11:11 A.M. with STNA #814 revealed she was the escort when Resident #56 was transported to the appointment. She stated when they arrived at the appointment, it was canceled so they were on their return trip to the facility. STNA #814 indicated a car jumped in front of the bus and hit their brakes causing the transport van driver to hit the brakes and Resident #56 to slide out of her wheelchair. STNA #814 indicated she was in one of the front passenger seats and was not (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 09/05/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few close enough to the resident to help the resident. She stated she observed the resident hit her knees on the back of the last row of seats and then roll out of the wheelchair onto the floor of the transport van. STNA #814 indicated she was told Resident #56 refused the safety harness. When questioned, she stated she did not actually hear Resident #56 refuse the restraint harness as she was standing outside the bus when Resident #56 was loaded. An additional interview on 09/05/23 at 12:52 P.M. with Resident #56 revealed she had never refused the safety harness and stated the driver just did not put it on her. Review of the Transportation, Diagnostic Services policy, revised 04/2009 revealed the facility would assist residents in arranging transpiration to/from diagnostic appointments when necessary. Review of the Van Transport policy (put in place as a result of the accident involving Resident #56) revealed if a resident was noted, or you were made aware of a resident, sliding out of a chair prior to transport, notify the Director of Nursing (DON) or Administrator to ensure the resident was transported by a stretcher. Ensure that the resident was appropriately secured with a seat belt prior to any resident transport. The seat belt should be secured around the resident, not the arm rests. In case of a fall during transportation or vehicle accident involving the transport van, notify 911 immediately, notify the Administrator and/or DON, never move the resident, or allow the chaperone to move the resident, even if the resident did not appear hurt. Never attempt to transfer the resident back to the chair. Advise them to stay where they were until a medical professional arrived on the eocene to check on them. This deficiency represents non-compliance investigated under Complaint Number OH00146049. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 3 of 3