Inspection·January 17, 2024

F 0684 physician. Level of Harm - Minimal harm or potential for actual harm Phone interview on 01/08/24 at 4:05 P.M., with LPN #379 confirmed she signed for the treatment as completed on Resident #5 on 01/07/24 before completing the treatment. LPN #379 revealed she got busy and did not do it. Residents Affected - Few Phone interview on 01/10/24 at 11:10 A.M., with LPN #373 confirmed she signed for the treatment as completed on Resident #5 on 01/06/24 before completing the treatment. LPN #373 revealed she got busy and overlooked it. Interview on 01/10/24 at 1:20 P.M., with Director of Nursing (DON) revealed she would expect the nurses to complete each residents wound care as ordered by the physician. Review of the undated policy titled, Wound Care, included to verify there was a physician order and apply the treatment as indicated. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 2 of 14 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 01/17/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, the facility failed to provide timely incontinence care for a resident. This affected one (#86) of three residents reviewed for incontinence care. The facility census was 113. Findings include: Review for Resident #86's medical record revealed an admission date of 06/26/23. Diagnoses included heart failure, muscle weakness, failure to thrive, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was severely cognitively impaired. Resident #86 required extensive assistants of two persons with bed mobility, transfers, extensive assistants of one for toilet use and personal hygiene. Resident #86 was always incontinent of bowel and bladder. Review of the care plan dated 12/20/23 revealed Resident #86 had bladder incontinence related to vascular dementia and impaired mobility. Interventions included Check Resident #86 every two hours and as needed for incontinence. Wash rinse and dry the perineum. Observation on 01/08/24 at 8:36 A.M., revealed Resident #86 was lying in bed. Resident #86 had an odor of stool. Observation on 01/08/24 at 8:46 A.M., with Licensed Practical Nurse (LPN) #210 during medication administration for Resident #86 verified Resident #86 had an odor of stool. Observation revealed LPN #210 unfastened Resident #86's brief and lowered the top portion of the brief. Observation revealed stool and urine was present in Resident #86's brief covering the top and bottom portion of the peri area. Observation revealed LPN #210 refastened Resident #86's brief without providing peri care for Resident #86. Observation revealed LPN #86 then continued medication administration for additional residents without notifying any staff Resident #86 required assistants with incontinence care. Observation on 01/08/24 at 11:08 A.M., revealed Resident #86 was lying in bed. Resident #86 had an odor of stool. Interview on 01/08/24 at 11:10 A.M., with State Tested Nursing Assistant (STNA) #253 revealed she was the only STNA on the first floor and she was assigned to Resident #86 who was located on the first floor. STNA #253 revealed she last checked on Resident #86 at 8:30 A.M. Resident #86 was clean and dry. STNA #253 revealed she was going to go on break then when she returned, she would check on Resident #86 again. Request made by surveyor to check Resident #86 due to odor of stool. Observation with STNA #253 revealed partially dried stool and urine were present in Resident #86's brief covering the top and bottom portion of the peri area. STNA #253 revealed the nurse did not inform her Resident #86 required assistants with incontinence care and confirmed she had not provided any incontinence care for Resident #86 throughout her shift. Interview on 01/08/24 at 11:20 A.M., with LPN #210 confirmed she and STNA #253 were the only two staff members assigned to care for residents on the first floor. No other staff had assisted with care. LPN #210 confirmed she did not inform STNA #253 that Resident #86 was incontinent of bowel and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 3 of 14 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 01/17/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bladder and required assistants with care. LPN #210 confirmed she was aware Resident #86 was incontinent of bowel and bladder at 8:36 A.M. and confirmed she did not assist Resident #86 with incontinence care and did not notify any staff of Resident #86's need for assistance with incontinence care at any time throughout the shift. Interview on 01/09/24 at 1:20 P.M., with Director of Nursing (DON) revealed residents are to be assisted with incontinence care at the time they are found to be incontinent. Review of the undated policy titled, Activities of Daily Living, Supporting, revealed residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutritional, grooming, and personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Numbers OH00148931, OH00149864, and OH00149509. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 4 of 14 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 01/17/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy, the facility failed to secure medications on a secured behavioral unit where 45 residents resided. This had the potential to affect 31 (#37, #42, #103, #4, #11, #107, #3, #80, #23, #26, #100, #21, #19, #45, #88, #60, #16, #31, #71, #5, #99, #115, #90, #75, #94, #69, #32, #91, #13, #49, and #56) independently mobile residents of 45 residents residing on the unit. The facility census was 113. Findings include: Observation on 01/09/24 at 1:13 P.M., on the third-floor behavioral unit revealed the medication cart, located near the nurses station, was unlocked and unattended. Observation revealed multiple residents were wandering near and around the nurses station. Unit Manager #273 was made aware and confirmed the medication cart with multiple residents medications, was left unsecured and unattended. Interview at the time of the observation, Licensed Practical Nurse (LPN) #317 returned to the medication cart and confirmed she left the cart unlocked and unattended and was unable to view the medication cart while she was gone. Observation on 01/10/24 at 12:22 P.M., on the third-floor behavioral unit revealed the medication cart, located on the residential hall was unlocked and unattended. Several residents were observed wandering on the hall near the medication cart. LPN #317 was observed opening the door to room [ROOM NUMBER] and exiting the room several minutes later. LPN #317 confirmed she left the medication cart unlocked which held several residents medications, while behind a closed door out of view and reach of the medication cart. Interview on 01/10/24 at 1:20 P.M., with Director of Nursing (DON) revealed expectations are the nurses were to keep the medication carts locked at all times when not in direct view. Review of the undated policy titled, Storage of Medication, revealed compartments, including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 5 of 14 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 01/17/2024 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and policy review, the facility failed to provide routine dental and oral care for a resident dependent on staff for all activities of daily living. Residents Affected - Few Actual Harm occurred when Resident #65 was not provided routine dental/oral care and treatment resulting in the resident expressing pain in his mouth, the resident's gums being red and inflamed with areas of dried blood, multiple broken, cracked, split, black upper and lower teeth, and foul-smelling breath. The lack of routine dental care had the potential to lead to serious complications including but not limited to infection and/or sepsis. This affected one (#65) of five residents reviewed for dental care. The facility census was 113. Findings include: Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage, muscle weakness, and contractures unspecified joint. Review of the physician's orders dated 07/12/22 revealed Resident #65 received Isosource 1.5 formula via gastrostomy (peg) tube every shift and also a regular (oral) diet as tolerated. A physician order dated 07/12/22 indicated may have dental evaluation and treatment as indicated. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had no abnormal mouth tissue, no inflamed or bleeding gums, but had obvious or likely cavity or broken natural teeth. Review of the care plan dated 02/15/23 revealed Resident #65 had dental health problems related to cavities and poor dentition. Interventions include monitor/document/ report to MD signs or symptoms of oral/dental problems needing attention such as pain, abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed. Provide mouth care as per activity of daily living personal hygiene and dental consult as needed. Review of the medical records for Resident #65 for March 2023 revealed no documentation of Resident #65 refusing oral care, Resident #65's condition of oral cavity or refusal to see a dentist. Review of the physician's orders dated 03/20/23 revealed an order for chlorhexidine gluconate solution 0.12% give 15 milliliter (ml) by mouth two times a day for oral hygiene, swab patients mouth with solution. Review of the form titled Dental Hygiene Encounter for Resident #65 dated 03/29/23 completed by Registered Dental Hygienist #380 revealed Resident #65 suffered from muscle atrophy and could not brush or floss teeth. Resident #65 tolerated scaling and debridement. Further review of the medical record revealed no further description or update provided of the resident receiving dental care. Review of the annual MDS dated [DATE] revealed Resident #65 had no abnormal mouth tissue, no inflamed or bleeding gums, but had obvious or likely cavity or broken natural teeth. Review of the quarterly MDS assessment dated [DATE] revealed Resident #65 was cognitively intact and had no dentures. Resident #65 was dependent for all activities of daily living and received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 6 of 14 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 01/17/2024 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 0790 Level of Harm - Actual harm Residents Affected - Few routine pain medication. This MDS assessment only included information regarding dentures and does not evaluate the resident's overall oral condition/status. Record review revealed no comprehensive oral assessment was completed for the resident at this time. Review of the care plan dated 11/13/23 revealed Resident #65 had an activity of living self-performance deficit which included related to weakness and contractures. Interventions included Resident #65 required total staff participation with personal hygiene and oral care. Review of the progress notes for Resident #65 from 10/01/23 through 01/09/24 revealed no assessment or follow up documented regarding Resident #65's oral status. Review of the documentation on the Medication Administration Record (MAR) for Resident #65 for December 2023 through January 2024 revealed nursing staff were documenting Resident #65 was receiving chlorhexidine gluconate solution 0.12% give 15 ml by mouth two times a day per nursing staff. Observations and interview on 01/09/24 between 9:52 A.M. and 12:25 P.M., revealed Resident #65 was lying in bed with continues tube feeding running. Resident #65 was severely contracted in the upper and lower extremities. Resident #65 had a strong foul mouth odor as he spoke. Observation revealed Resident #65's gums were red and inflamed with areas of dried blood. Resident #65 had multiple broken, cracked, split, and black upper and lower teeth. An interview with Resident #65 at the time of the observation revealed he had not seen a dentist since admission to the facility. Resident #65 revealed he didn't like mouth care because it was painful when mouthcare was provided. During the interview, the resident indicated he would like to see the dentist. Interview on 01/09/24 at 12:42 P.M., with Licensed Practical Nurse (LPN) #304 confirmed Resident #65's foul mouth odor, swollen red inflamed gums with multiple broken black teeth. LPN #304 stated Resident #65's mouth, gums and teeth had always been that way. LPN #304 stated Resident #65 frequently refused oral care (she was unsure why), but felt staff offered and he refused. LPN #304 stated Resident #65 never refused a dentist but felt he would need to see an oral surgeon because of his contractures and oral surgeons didn't come to the facility. Interview on 01/09/24 at 5:02 P.M., with the Director of Nursing (DON) revealed she was unaware of any concerns with Resident #65's teeth and gums. Observation of Resident #65's oral condition with DON confirmed Resident #65 had a foul odor from his mouth while speaking, the upper and lower gums continued to be swollen, red and the resident had multiple broken and black teeth. Dried blood was noted on the resident's teeth. The DON confirmed Resident #65's oral condition needed addressed and stated Resident #65 needed to consult with a dentist. Interview on 01/10/24 between 11:52 A.M. and 11:55 A.M., with LPN #374 and State Tested Nursing Assistant (STNA) #282 revealed they had both worked with Resident #65 for several months. Resident #65's teeth and gums had been in the same condition, broken teeth, multiple carries, swollen and bleeding. Interview on 01/10/24 at 4:40 P.M., with Social Worker Designee (SWD) #238 revealed the dentist and dental hygienist visited residents at the facility monthly or every other month but not on the same date, they would come at different visits and see residents. They would give her a list of according to payment source who they were going to see on the scheduled visit. SWD #238 revealed she was unsure how frequently or when a resident should be scheduled to see a dentist. SWD #238 revealed Resident #65 was seen by the Dental Hygienist on 03/29/23 and verified Resident #65 had never seen a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 7 of 14 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 01/17/2024 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 0790 dentist since residing at the facility. Per SWD #238, Resident #65 refused to see a dentist at that time and since then, there were no consultations with the dentist offered or scheduled for Resident #65. Level of Harm - Actual harm Residents Affected - Few Interview on 01/17/24 at 10:47 A.M., with Resident #65 revealed he gets his food through a bag (tube feed), so he does not need to use his teeth. Resident #65 went on to state if I leave them (teeth) alone, they don't hurt, I don't want to eat because I have my bag (tube feed). Observation at the time of the interview revealed Resident #65's gums were inflamed and bright red, and multiple broken, cracked, split, black upper and lower teeth. Interview on 01/17/24 at 11:31 A.M., with State Tested Nurse Aide (STNA) #282 confirmed she routinely cared for Resident #65. STNA #282 revealed Resident #65 never allowed anyone to do mouth care on him in the past. STNA #282 revealed today was the first day he agreed to do mouth care. STNA #65 confirmed she provided mouth care for Resident #65 this A.M. STNA #282 revealed she did not document Resident #65's refusals of mouth care in the past and confirmed with record review of the documentation of oral care in the electronic medical record, there was a section in the electronic medical records where she could document refusals. STNA #282 revealed, I need to get on it. Interview on 01/17/24 at 11:40 A.M., with LPN #304 confirmed she routinely cared for Resident #65. LPN #304 confirmed she documented on the MAR administering the chlorhexidine gluconate solution 0.12%. LPN #304 stated Resident #65 had never allowed staff to administer it, he always refused. LPN #304 revealed the nurses documented they attempted to do it when they signed the MAR. LPN #304 confirmed she never documented he refused the chlorhexidine gluconate solution 0.12%. Review of the State Tested Nursing Assistant (STNA) electronical documentation of activities of daily living for Resident #65 revealed a section for oral care. Within the section was an area for documentation of resident refusals of oral care. Record review for January 2024 revealed no documentation of refusals of oral care for Resident #65. Staff were documenting care was being provided, even though per interview the resident was frequently refusing the care. Review of the undated policy titled, Dental Services, revealed routine and emergency dental services were available to meet the resident oral health services in accordance with the resident assessment and plan of care. Social Service Representatives would assist residents with appointments, transportation, arrangements and for reimbursement for dental services under the state plan, if eligible. This deficiency represents non-compliance investigated under Complaint Number OH00149864. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 8 of 14 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 01/17/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident interviews, staff interviews, record review, and review of food committee notes, the facility failed to ensure food was served at the preferred temperature and was palatable. This had the potential to affect all residents except Resident #27, #95, and #96 who received nothing by mouth (NPO). The facility census was 113. Residents Affected - Many Findings include: Record review of the food committee meeting dated 11/02/23 at 2:30 P.M., revealed concerns by residents to Dietary Manager #351 which included staff needed more training, concerns with how food gets to residents, burgers are not good, oatmeal was runny, pancakes were hard, and soups were cold. Observation and interview on 01/09/24 12:50 P.M., revealed dietary [NAME] #272 plated the lunch meal from a steam table in the kitchen. As [NAME] #272 plated the vegetables, observation with Dietary Manager #351 revealed [NAME] #272 quickly scooped the undrained vegetables (with the watery liquid the vegetables were cooked in), onto each plate saturating all food items. As the tray line neared an end, the surveyor requested a test tray be prepared and placed on the third food cart. Observation was made as the test tray was prepared, placed on the cart at 1:02 P.M., and transported by staff to the third floor where it arrived at 1:05 P.M. The test tray remained on the cart in view of the surveyor, until all other trays were distributed to residents. The test tray was removed from the cart at 1:15 P.M., by Dietary Manager #351 who used a facility thermometer that confirmed the temperatures of the pork which was 105.6 degrees Fahrenheit (F), the roasted potatoes were 104 degrees F, and the mixed vegetables were 120 degrees F. Immediately following confirmation of the test tray temperatures, the surveyor, and Dietary Manager #351 taste-tested the pork which was difficult to cut, tough to chew and had bland taste. The roasted potatoes were dry, overcooked and had a bland taste, the vegetables were also watered down, and had bland flavor. Per Dietary Manager #351, he would rate the food a two on a scale of one to five. which were not found to be palatable, overcooked, and at unsatisfactory temperatures. The presentation of food items on the plate was not pleasing to the eye. Interviews on 01/09/24 between 1:24 P.M. and 1:52 P.M., with Resident #61, #108, #30, #28, #1, #50, and #74 revealed the lunch meal was not satisfactory temperature and was not palatable. This deficiency represents non-compliance investigated under Complaint Number OH00149509. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 9 of 14 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 01/17/2024 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 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 safely store food and maintain a clean and sanitary kitchen and follow up on dietitian sanitation audits. This had the potential to affect all residents except Resident #27, #95, and #96 who received nothing by mouth (NPO). The facility census was 113. Findings include: Observation and interview on 01/09/24 at 11:06 A.M., with Dietary Manager #351 of the kitchen revealed the burners on the stove top had a large amount of charred black build up on each burner. Overflow of charred spilled food items were on the stove below the burners. Under the fryer and grill on the floor located next to the stove was a large amount of grease and dirt build up. Black and brown French fries and food crumbs were throughout the thick grease build up. Inside the fryer was black oil covered with floating food particles including blackened French fries. The food steamer door was very oily, the shelves had a buildup of oil debris and food particles. The convection oven also had a large amount of grease and particle build up. The floors throughout the kitchen in every section was very dirty with food crumbs, dried spills dirt and dust, there were green beans and carrots smashed into the floor with staff observed walking over and on top of them. Dietary Manager #351 stated the green beans were served the previous day at lunch time. The drain next to the cooking appliances had a very thick black build up surrounding the entire drain. The second drain also had a large buildup of a black substance and two ink pens inside the drain. Dietary Manager #351 stated, Yes, the floors are nasty. Observation of the freezer with Dietary Manager #351 confirmed seven small pizzas wrapped in a clear facility wrap and undated. Multiple uncooked hamburger patties were observed in a large open bag undated and opened to the air. A large bag of garlic bread was also left opened and exposing the bread. Observation revealed inside the walk-in cooler was a large opened, undated bag of celery. The celery was opened to the air and was brown on both ends of each of the multiple stalks. The walk-in cooler also included a partial container of tuna fish undated, partially used chicken soup undated, gravy and sweat and sour sauce partially used and undated, and cheese that was unwrapped, opened to the air and undated. Dietary Manager #351 confirmed all items. Review of the Sanitation Audit, dated July 2023, completed by Dietitian #371, revealed baseboards in need of cleaning, floors under some equipment in need of cleaning, floors slippery behind the steam table area, dust observed around vents, wall behind stove in need of cleaning, food spatters observed on clean dishes, shelves under the steam table in need of cleaning, slicer covered, food debris observed on the slicer, griddle on back of stove in need of cleaning, floor drain in dish area in need of cleaning, oven in need of cleaning, both convection ovens in need of cleaning, many boxes, cans, bags in dry storage not dated, containers in the cooler not labeled/dated, staff handling silverware on the tray line while licking fingers to separate meal tickets. Review of the Sanitation Audit, dated November 2023, completed by Dietitian #371, revealed floor corners in need of cleaning, walls in need of cleaning, piping under sinks in need of cleaning, counters not thoroughly cleaned after use, trash not covered, food debris observed on clean glassware, utility carts and dish caddies in need of cleaning, slicer not thoroughly cleaned, dried meat observed on slicer, griddle in need of cleaning, oven in need of cleaning, convection oven in need of cleaning, bags, boxes, cans, containers not dated, foods not being labeled. Dated in cooler/refrigerator, temperature of foods was not taken before being served, and poor presentation of pureed plates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 10 of 14 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 01/17/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the Sanitation Audit, dated December 2023, completed by Dietitian #371, revealed floor corners in need of cleaning, floor behind the steam table, under equipment in need of cleaning, wall behind the stove, sink and slicer in need of cleaning, piping under sinks in need of cleaning, prep tables in need of cleaning, station area in need of cleaning, slicer in need of cleaning, grill in need of cleaning, oven including convection ovens in need of cleaning, floor in cooler in need of cleaning, boxes, bags, cans, containers not dated, and some foods not labeled or dated in walk in cooler. Interview 01/09/24 at 12:00 P.M., with Dietitian #371 revealed there were a lot of improvements to be made and she had made recommendations documented on Sanitation Audits and given to the Dietary Manager and Administrator. Review of the policy titled, Storage of Food in Refrigeration dated 09/2019, revealed food being returned to storage after cooking or preparation must be covered, all containers must be labeled with the contents and date food items were placed in storage. Review of the policy titled, General Cleaning and Sanitation dated 2010, revealed a clean working environment is essential to good sanitation practices. Sanitation practices involve both cleaning and sanitation. Basic requirements include the following, all work and storage areas are kept clean, free from dust, all walls, floors, and ceilings are cleaned thoroughly, all equipment and surfaces are washed, rinsed, and sanitized after each use to prevent cross contamination. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 11 of 14 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 01/17/2024 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 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. Based on observation, staff interview and record review, the facility failed to maintain accurate medical records for residents. This affected two (#5 and #65) of five medical records reviewed. The facility census was 113. Findings include: 1. Review for Resident #5's medical record revealed an admission date of 10/26/22. Diagnoses included dementia, and unspecified psychosis. Review of the physician order dated 01/05/24, for Resident #5 revealed an order to clean the left lower leg with normal saline, pat dry, apply xeroform, an abdominal dressing (ABD) and kerlix every day shift. Observation on 01/08/24 at 2:53 P.M., with Wound Care Nurse/Registered Nurse (RN) #257 and Assistant Director of Nursing (ADON) #273 complete wound care for the wound on Resident #5's left lower leg revealed the old dressing on Resident #5's wound to the left lower leg was dated 01/04/24. ADON #273 removed the old dressing and confirmed the dressing was dated 01/04/24. ADON #273 revealed they probably got behind and forgot, they probably thought the wound nurse would look at it Monday anyway. Review of the Treatment Administration Record (TAR) dated January 2024 for Resident #5 revealed on 01/05/24 the wound care was not signed as completed for Resident #5. On 01/06/24, Licensed Practical Nurse (LPN) #373 signed the TAR confirming the wound care to Resident #5's left lower leg was completed. On 01/07/24, LPN #379 signed the TAR confirming the wound care to Resident #5's left lower leg was completed. Interview on 01/08/24 at 3:20 P.M., with Wound Care Nurse/RN #257 confirmed at times, she found nurses were not completing the scheduled wound care for residents daily as ordered. Wound Care Nurse/RN #257 revealed she would expect the nurses to complete each residents wound care as ordered by the physician. Phone interview on 01/08/24 at 4:05 P.M., with LPN #379 confirmed she signed for the treatment as completed on Resident #5 on 01/07/24 before completing the treatment. LPN #379 revealed she got busy and did not do it. Phone interview on 01/10/24 at 11:10 A.M., with LPN #373 confirmed she signed for the treatment as completed on Resident #5 on 01/06/24 before completing the treatment. LPN #373 revealed she got busy and overlooked it. 2. Review of Resident #65's medical record revealed an admission date of 07/12/22. Diagnoses included traumatic subdural hemorrhage, muscle weakness, contracture unspecified joint, and need for assistants with personal care. Record review of the State Tested Nursing Assistant (STNA) electronic medical records for Resident #65 revealed a section for oral care. Within the section was an area for documentation of resident refusals of oral care. Record review for January 2024 revealed no documentation of refusals of oral care for Resident #65. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 12 of 14 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 01/17/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/17/24 at 11:31 A.M., with STNA #282 confirmed she routinely cared for Resident #65. STNA #282 confirmed Resident #65 never allowed anyone to do mouth care on him in the past. STNA #282 confirmed she did not document Resident #65's refusals of mouth care in the electronic medical records. STNA #282 revealed, I need to get on it. Record review of the physician orders revealed an order for Resident #65 dated 03/20/23 for chlorhexidine gluconate solution 0.12% give 15 milliliters (ml) by mouth two times a day for oral hygiene, swab patients mouth with solution. Record review of the documentation on the Medication Administration Record (MAR) for Resident #65 for December 2023 and January 2024 revealed nursing staff documented Resident #65 received chlorhexidine gluconate solution 0.12% give 15 ml by mouth two times a day per nursing staff. Review of the MAR revealed there were codes for nursing staff to utilize when a resident refused. Interview on 01/17/24 at 11:40 A.M., with LPN #304 confirmed she routinely cared for Resident #65. LPN #304 confirmed she documented on the MAR for Resident #65 for the chlorhexidine gluconate solution 0.12%. LPN #304 revealed Resident #65 never allowed them to do it, he always refused. LPN #304 revealed the nurses signed the MAR relaying they attempted to do the ordered treatment when they signed the MAR. LPN #304 confirmed she never documented he refused the chlorhexidine gluconate solution 0.12%. Interview and record review on 01/17/24 at 2:09 P.M., with Director of Nursing (DON) confirmed inaccurate documentation in Resident #65's MAR. DON revealed when a nurse signs off the MAR, that means the medication was administered or the treatment was completed. There would be a specific code marked on the MAR if the resident refused. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 13 of 14 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 01/17/2024 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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm Based on personnel file review and staff interview, the facility failed to employ a qualified social worker on a full-time basis as required. This had the potential to affect all 113 residents residing in the facility. The facility census was 113. Residents Affected - Many Findings include: Interview on 01/09/24 at 10:16 A.M., with Social Worker Designee (SWD) #238 revealed she was not a licensed social worker (LSW). SWD #238 revealed she worked with all the residents in the facility, she was the only SWD and there was no LSW employed at the facility. SWD #238 revealed she had no prior experience in long term care as a social worker prior to starting at this facility and revealed she received no training by a LSW during employment at the facility. Interview on 01/09/24 at 10:32 A.M., with the Administrator confirmed the facility was certified and licensed for 150 beds. The Administrator confirmed the facility did not employ a LSW and had not employed a LSW for over two years. The Administrator confirmed he was aware the facility was required to employ a LSW based on the number of beds the facility had. Review of the personnel file for SWD #238 with Human Resource (HR) #279 revealed SWD #238 had a hire date of 04/27/22. Interview with HR #279 confirmed SWD #279 was not an LSW or met the qualifications. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 14 of 14