Inspection·March 7, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility investigation, and interview the facility failed to ensure timely physician notification after a resident sustained a scald burn. This affected one resident (#39) of six residents (#39, #55, #66, #77, #98, and #221) reviewed for accidents. The facility census was 111. Findings Include: Review of the medical record for Resident #39 revealed an initial admission date of 03/06/19. Diagnoses included muscle weakness, diabetes mellitus, and systemic lupus erythematosus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition, no behaviors, and no skin issues. Review of the skin/wound note dated 01/30/24 timed 7:29 P.M. revealed upon exiting the elevator Resident #39 approached the nurse and asked the nurse to look at her thigh. The nurse observed blisters and burn areas to the right thigh. The nurse asked Resident #39 what happened, and the resident stated she was in bed for the night and asked one of the aides to warm up her soup and she ended up spilling the soup on her lap while lying in bed. The note indicated the physician was aware. Review of the Wound Assessment and Plan note dated 01/30/24, authored by the wound physician, revealed Resident #39 had a right anterior thigh burn that measured 15 centimeter (cm) length x 16 cm width x <0.1 depth. The documentation further indicated a scald burn to anterior right thigh, first and partial thickness second degree. Review of the facility's investigation dated 01/10/24 (untimed) revealed on 01/30/24 at 7:30 A.M. Licensed Practical Nurse (LPN) #314 was exiting the elevator and Resident #39 approached and asked her to look at her thigh. LPN #314 observed blisters and burn areas to the right thigh. LPN #314 asked Resident #39 what happened and the resident stated she was in bed for the night and asked one of the aides to warm up her soup and she ended up wasting the soup on her lap while lying in bed. The wound team was making wounds and LPN #314 asked for assistance and at that point, the wound nurse and physician took it from there. Once the wound team completed their wound rounds, the wound nurse educated staff on warming resident meals and liquids. Interview on 03/05/24 at 4:58 P.M. with Resident #39 revealed at the time of the incident on 01/29/24, she had not been feeling well and had not eaten much for a couple of days. Resident #39 wanted soup and asked one of the aides to warm up the soup for her. Resident #39 was in bed and spilled the soup on herself as she was trying to eat the soup. There were two STNAs in room and one STNA left the room. Resident #39 thought the STNA left the room to get the nurse; however, the nurse did not come. Resident #39 thought they were busy and had forgotten about her. Resident #39 said STNA #449 was the STNA that stayed in the room with her and STNA #449 put barrier cream on the burn which helped to cool it down and soothe the pain. When Resident #39 woke up the next morning the skin had welted up. Resident #39 stated she did not see a nurse the night the burn occurred but saw a nurse with the wound physician the next day on 01/30/24. Interview on 03/05/24 at 5:22 P.M. with STNA #449 revealed she was not in the room when Resident #39 spilled the soup onto herself and was not the STNA who brought her the soup. STNA #449 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 2 of 22 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 03/07/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few saw the burn a few hours later on 01/29/24 sometime between 7:00 P.M. and 8:00 P.M. while changing Resident #39. STNA #449 asked Resident #39 what happened, and she told her she had spilled soup onto herself. STNA #449 put barrier cream on the area and then reported it to one of the nurses working that evening but was not sure which nurse she had told. Interview on 03/06/24 at 2:48 P.M. with Wound Nurse (WN) #363 revealed on 01/30/24, while she was making wound rounds, the nurse reported Resident #39 had a burn wound. WN #363 contacted the night nurse from 01/29/24 via phone to see why it had not been reported that night. The night nurse told her she was not aware that it happened. WN #363 stated she thought Resident #39 did not tell anyone what happened because she did not want to get the STNA in trouble. WN #363 stated Resident #39's burn was massive, and she was more worried about treating the burn. WN #363 said she educated staff on reporting because the burn was not reported timely. WN #363 stated she was glad they caught it on the day of wound rounds because treatments were put in place. Follow-up interview on 03/07/24 at 11:37 A.M. with WN #363 confirmed the burn occurred on 01/29/24 and Resident #39's physician and everyone else was not notified until the next day on 01/30/24 by LPN #314. The facility did not provide evidence of education provided to staff regarding reporting injuries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 3 of 22 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 03/07/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 10. Observations on 03/04/24 from 9:30 A.M. to 10:00 A.M. of the third-floor unit revealed Resident #60 had a folded blanket on the bottom of his recliner that was soiled with dry food/beverage and feces. Further observation revealed Resident#52 was lying in bed and there was dried red liquid covering Resident #52's bedrail, and empty straw wrappers, open butter containers, and miscellaneous food debris scattered on the floor throughout the room. Resident #52's privacy curtain was stained with miscellaneous food and liquids. Observation and interview on 03/04/24 at 10:09 A.M. with the Director of Nursing (DON) verified the observations. Review of the facility policy Maintenance Service revised December 2008, revealed maintenance service would be provided to all areas of the building, grounds, and equipment. Functions of the maintenance personnel included but was not limited to, maintaining the building in good repair and free from hazards. Review of the facility's undated policy Cleaning and Disinfecting Residents' Rooms revealed surfaces (e.g., floors, tabletops) were to be cleaned on a regular basis, when spilled occurred, and when the surfaces were visibly soiled. Environmental surfaces were to be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces were visibly soiled. Walls, blinds, and window curtains in resident room areas were to be be cleaned when the surfaces were visibly contaminated or soiled. Review of the census report provided by the facility revealed Residents #2, #5, #9 #11, #17, #22, #25, #28, #29, #31, #32, #33, #35, #39, #40, #42, #43, #45, #47, #50, #53, #54, #55, #56, #59, #66, #68, #70, #72, #73, #75, #84, #85, #87, #90, #94, #97, #98, #99, #100, #105, #106, #107, #109, #110, #118, #119, and #120 resided on the second floor. 8. Observation on 03/04/24 at 12:04 P.M. of the [NAME] Shower Room on the second floor revealed dirty linens on the floor, wadded up paper on the floor, and the clean linen cart was uncovered with a dirty urinal beside the uncovered clean linen cart. Observation and interview on 03/04/24 at 12:02 P.M. with LPN #413 verified the observations. 9. Observation on 03/05/24 at 9:31 A.M. revealed the call light in Resident #219's room was pulled out of the wall, and the wall where a hazardous needle collection box had been removed remained unpainted. On 03/05/24 at 9:38 A.M., STNA #439 verified the observations. Based on observation, interview, and policy review the facility failed to ensure a clean, sanitary and well maintained environment. This affected 51 residents, 48 who resided on the second floor (#2, #5, #9 #11, #17, #22, #25, #28, #29, #31, #32, #33, #35, #39, #40, #42, #43, #45, #47, #50, #53, #54, #55, #56, #59, #66, #68, #70, #72, #73, #75, #84, #85, #87, #90, #94, #97, #98, #99, #100, #105, #106, #107, #109, #110, #118, #119, and #120) and three who resided on the third floor (#60, #52 and #219). The facility census was 111. Findings Include: 1. Observation of Resident #75's room on 03/04/24 at 10:17 A.M. revealed an entertainment pole that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 4 of 22 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 03/07/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some held a screen. The pole down to the base had splattered dried tan colored substance on it. Observation of Resident #75's tube feeding pump and the pole that held the pump revealed dried tan colored substances along the pole and at the base of the pole. Follow-up observation of Resident #75's room on 03/05/24 at 1:48 P.M. revealed the dried tan substance remained on the entertainment and tube feeding poles and there was a hole in the wall behind the entrance door that lined up with the doorknob. Interview at the time of the observation with Stated Tested Nurse Aide (STNA) #344 verified the observations. STNA #344 stated the dried tan colored substance on the tube feeding and entertainment poles was dried tube feeding. 2. Observation of Resident #28's room on 03/04/24 at 10:22 A.M. revealed a small trash bin located by the door. Deep gashes were noted in the wall. Follow-up observation on 03/05/24 at 1:56 P.M. revealed in addition to the deep gashes in the wall there were several dried brownish colored stains on the wall. Interview at the time of the observation with STNA #373 verified the observations and stated the gashes in the wall were probably from the trash bin because they were the same height. 3. Observation of Resident #17's room on 03/04/24 at 11:04 A.M. revealed the foot board of Resident #17's bed was leaning against the dresser. Resident #17 stated it was broke and had been that way for a long time. Further observation of Resident #17's room revealed the molding behind the bed was falling off the wall and there were dried red stains on the air conditioner unit. Interview on 03/05/24 at 2:08 P.M. with STNA #391 verified the observations and stated the foot board had been that way since the beginning of February 2024. Further observations during the interview with STNA #391 revealed several dried, brownish stains/splatter on the wall near the television of the vacated roommate side of the room. STNA #391 verified the observation. 4. Observation of Resident #120's room on 03/04/24 at 11:20 A.M. revealed black stains on floor near the bed; the bottom piece of the air conditioning unit was missing; there was missing floor tile underneath the floor of the bed; the flooring throughout the room was dirty, and near the bathroom door there was missing molding and holes in the wall. Interview on 03/05/24 at 2:11 P.M. with STNA #391 verified the observations and noted Resident #120's television had been off the wall since the resident was admitted mid-February 2024. Observation at the time of the interview revealed Resident #120's television was sitting on the dresser. The television had no feet or stand to keep it in the upright position, it was propped up on a package of cleaning wipes and leaning against the wall. 5. Interview on 03/04/24 at 12:21 P.M. with Resident #54 revealed the resident thought housekeeping could be better. Observation of Resident #54's room, at the time of the interview, revealed the floor was sticky and had scattered black spots, and the wall near the bathroom was in disrepair and had various stains. Follow-up observation and interview with Resident #54 on 03/05/24 at 2:01 P.M. revealed housekeeping had not been in his room yet and the surveyor should observe the bathroom. Observation with Licensed Practical Nurse (LPN) #413 revealed the floor remained sticky and had various debris scattered about. Observation of the bathroom revealed two large white plastered areas on the ceiling that had not been painted over. LPN #413 confirmed the observations and stated she had no idea how long it had been since the ceiling had been plastered and left unpainted. 6. Observation of Resident #39's room on 03/04/24 at 12:38 P.M. revealed the wall near the bathroom had cracks and crumbling plaster; brownish stains on wall near the trash bin by the entrance door; molding off the wall near the closet and bathroom door, and the paint on the closet doors was scraped. Interview and observation on 03/05/24 at 2:10 P.M. with STNA #391 verified the observations. 7. Observation on the second floor across from the nurse's station facing the dining room on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 5 of 22 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 03/07/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm 03/05/24 at 2:15 P.M. revealed a large area on the bottom part of the wall near the molding that had a hole with crumbling plaster. Interview at the time of the observation with LPN #413 verified the observation. LPN #413 was not sure but thought the wall had been like that for a couple weeks after a resident ran into the wall with their power wheelchair. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 6 of 22 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 03/07/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to ensure admission and annual Minimum Data Set (MDS) assessments were completed timely for seven residents (#39, #55 #66, #76, #98, #129, and #224) of 27 residents reviewed for completed MDS assessments. The facility census was 111. Findings Include: On 03/06/24, review of the medical record for Resident #39 revealed an incomplete annual MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #55 revealed an incomplete annual MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #66 revealed an incomplete annual MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #76 revealed an incomplete annual MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #98 revealed an incomplete annual MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #129 revealed an incomplete admission MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #224 revealed an incomplete admission MDS assessment dated [DATE]. Interview on 03/06/24 at 3:32 P.M. with MDS coordinator/Licensed Practical Nurse #380 revealed there was not enough staff to timely complete and transmit the MDS assessments. Many of the MDS assessments that were not completed were waiting for social service input. A group of export ready MDS assessments were completed and locked 03/04/24 but had not been transmitted. Review of the online Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility RAI 3.0 User's Manual revealed quarterly MDS assessments must be completed every 92 days. The MDS assessments must be submitted to CMS no later than 14 days after the Assessment Reference Date (ARD). The admission MDS assessment completion date must be no later than day four of the resident's stay. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 7 of 22 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 03/07/2024 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility did not ensure quarterly MDS assessments were completed timely for four residents (#19, #72, #85, and #87) of 27 residents reviewed for completed MDS assessments. The facility census was 111. Residents Affected - Some Findings Include: On 03/06/24, review of the medical record for Resident #19 revealed an incomplete quarterly MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #72 revealed an incomplete quarterly MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #85 revealed an incomplete quarterly MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #87 revealed an incomplete quarterly MDS assessment dated [DATE]. Interview on 03/06/24 at 3:32 P.M. with MDS coordinator/Licensed Practical Nurse #380 revealed there was not enough staff to timely complete and transmit the MDS assessments. Many of the MDS assessments that were not completed were waiting for social service input. Review of the online Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility RAI 3.0 User's Manual revealed quarterly MDS assessments must be completed every 92 days. The MDS must be submitted to CMS no later than 14 days after the Assessment Reference Date (ARD). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 8 of 22 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 03/07/2024 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completing the assessment. This affected 22 residents (#4, #13, #29, #33, #41, #42, #43, #48, #55, #60, #61, #63, #72, #75, #76, #77, #87, #93, #96, #98, #107, and #219) of 31 residents reviewed for submitted MDS assessments. The facility census was 111. Residents Affected - Some Findings Include: On 03/06/24, review of the medical record for Resident #4 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #13 revealed an annual MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #29 revealed an annual MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #33 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #41 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #42 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #43 revealed an annual MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #48 revealed an annual MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #55 revealed an annual MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #60 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #61 revealed a discharge MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #63 revealed an annual MDS assessment dated [DATE] had not been transmitted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 9 of 22 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 03/07/2024 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 0640 Level of Harm - Minimal harm or potential for actual harm On 03/06/24, review of the medical record for Resident #72 revealed an incomplete quarterly MDS assessment dated [DATE] had not been completed or transmitted. On 03/06/24, review of the medical record for Resident #75 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. Residents Affected - Some On 03/06/24, review of the medical record for Resident #76 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #77 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #87 revealed an incomplete quarterly MDS assessment dated [DATE] had not been completed or transmitted. On 03/06/24, review of the medical record for Resident #93 revealed a quarterly MDS assessment dated [DATE], a discharge- return anticipated MDS assessment dated [DATE], and a discharge- return not anticipated MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #96 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #98 revealed an incomplete annual MDS assessment dated [DATE] had not been completed or transmitted. On 03/06/24, review of the medical record for Resident #107 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #219 revealed an admission MDS assessment dated [DATE] had not been transmitted. Interview on 03/06/24 at 3:32 P.M. with MDS coordinator/Licensed Practical Nurse #380 revealed there was not enough staff to timely complete and transmit the MDS assessments. Many of the MDS assessment that were not completed were waiting for social service input. A group of export ready MDS assessments were completed and locked 03/04/24 but had not been transmitted. Review of the online CMS Long-Term Care Facility RAI 3.0 User's Manual revealed quarterly MDS assessments must be completed every 92 days. The MDS must be submitted to CMS no later than 14 days after the Assessment Reference Date (ARD). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 10 of 22 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 03/07/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility failed to ensure residents who were dependent for activities of daily living (ADL) received nail care. This affected one resident (#75) of two residents (#19 and #75) reviewed for ADLs. The facility census was 111. Residents Affected - Few Findings Include: Review of the medical record for Resident #75 revealed an admission date of 07/12/22. Diagnoses included stroke, muscle weakness, and contractures. Review of the plan of care revised 07/21/23 revealed Resident #75 had an ADL self-care performance deficit related to weakness, contracture, wounds, and pain. Interventions included check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #75 had intact cognition and was dependent on staff for personal hygiene. Observation of Resident #75 on 03/04/24 at 10:17 A.M. revealed the resident's nails were long and dirty with black debris under the nails. Resident #75's hands were contracted. Interview on 03/05/24 at 1:48 P.M. with State Tested Nurse Aide (STNA) #319 verified the observation and stated it was the STNA's responsibility to complete nail care. Review of the undated facility policy Activities of Daily Living (ADLs), Supporting, revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. including appropriate support and assistance with hygiene (ex. bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 11 of 22 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 03/07/2024 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of a shipping receipt, the facility failed to provide corrective eye glasses in a timely manner. This affected one (Resident #37) of one resident reviewed for vision services. Residents Affected - Few Findings Include: Review of medical record for Resident #37 revealed an admission date of 11/11/21. Diagnoses included chronic obstructive pulmonary disease and chronic kidney disease. The resident had intact cognition. Interview on 03/04/24 at 9:30 A.M. with Resident #37 revealed he had an eye exam in 2023 and ordered glasses. Resident #37 had not received the glasses nor had he heard from staff regarding the glasses. Interview on 03/06/24 at 11:06 A.M. with Social Services (SS) #338 revealed Resident #37's eye glasses were in the back room of SS #338's office. SS #338 was not sure why Resident #37 had not been given the glasses. SS #338 had no information related to when the eye glasses were delivered to the facility. Interview on 03/06/24 at 11:32 A.M. with Optometrist #446, who completed Resident #37's eye exam, revaled Resident #37 had an eye exam on 11/13/23, was fitted for glasses on 12/04/23, and the glasses were ordered on 12/07/23. Optometrist #446 provided a copy of the shipping receipt which indicated Resident #37's eye glasses were delivered to the facility on [DATE]. Interview on 03/06/24 at 1:53 P.M. with the Director of Nursing verified that Resident #37's eye glasses were delivered on 12/15/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 12 of 22 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 03/07/2024 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a wound care report, investigative report, and staff and resident interviews, the facility failed to ensure Resident #39's environment remained free of an accident hazard when the resident's soup was served at an unsafe temperature causing an injury. This affected one resident (#39) of six residents reviewed for accidents. The facility census was 111. Actual harm occurred on 01/29/24 between approximately 5:00 P.M. and 6:00 P.M. when Resident #39 sustained first and second degree burns to her right anterior thigh after spilling soup which a State Tested Nursing Assistant (STNA) had warmed up in a microwave and served to Resident #39. The burn went unreported until the next day, 01/30/24, when Resident #39 asked a nurse to assess the area. The wound team observed the area on 01/30/24. The wound physician documented the wound as a as a scald burn to anterior right thigh, first and partial thickness second degree (Involves the top two layers of skin. The burn forms a blister and is very painful) measuring 15 centimeters (cm) length by 16 cm width with <0.1 depth. The resident voiced she had pain at the time of incident as a result of the injury and also reported as of 03/05/24 the burn was still healing and there was a bad scar. Findings Include: Review of the medical record for Resident #39 revealed an initial admission date of 03/06/19. Diagnoses included muscle weakness, diabetes mellitus, and systemic lupus erythematosus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition, no behaviors, and no skin issues. Review of a skin/wound note dated 01/30/24 timed 9:34 A.M. revealed Resident #39 was seen by the wound team. Resident #39 was observed to have first and second degree burns to the right anterior thigh. Measurements were 15 cm length by 16 cm width with 0.1 cm depth. One hundred percent epithelial tissue was noted with no exudate or signs or symptoms of infection. Treatment included application of Alocane Burn gel and cover with 7 x 7 border gauze. The skin/wound note indicated nursing was to offload pressure. Review of the skin/wound note dated 01/30/24 timed 7:29 P.M. revealed the nurse was exiting the elevator when Resident #39 approached the nurse and asked if the nurse would look at her thigh. The nurse observed blisters and burn areas to the right thigh. The nurse asked Resident #39 what happened, and Resident #39 said she was in bed for the night and asked one of the aides to warm up her soup and Resident #39 ended up spilling the soup on her lap. The skin/wound note indicated the physician was aware. Review of the Wound Assessment and Plan note dated 01/30/24 authored by the wound physician revealed Resident #39 had a right anterior thigh burn that measured 15 cm length by 16 cm width by <0.1 depth. The burn was described as a scald burn to anterior right thigh, first and partial thickness second degree. The plan indicated to offload pressure; Skin prep (protective barrier) to areas of serous blisters; Alocane burn gel to remaining areas twice a day, and protein supplementation and daily multivitamins. Review of the facility's investigation dated 01/30/24 (untimed) revealed on 01/30/24 at 7:30 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 13 of 22 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 03/07/2024 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 0689 Level of Harm - Actual harm Residents Affected - Few Licensed Practical Nurse (LPN) #314 was exiting the elevator when Resident #39 approached and asked her to look at her thigh. LPN #314 observed blisters and burn areas to the right thigh. LPN #314 asked Resident #39 what happened and the resident stated she was in bed for the night and asked one of the aides to warm up her soup and she ended up wasting the soup on her lap while lying in bed. The investigation indicated immediate action included the wound nurse and wound physician were on the hall making rounds and LPN #314 asked for their assistance. The wound nurse and physician took it from there and once they were done with their wound rounds, the wound nurse provided education on warming resident meals and liquids. Review of the plan of care dated 01/30/24 revealed Resident #39 had a potential for impairment to skin integrity related diabetes type 2, incontinence, and second degree burns to right thigh (01/29/2024). Interventions included informing and instructing staff of causative factors and measures to prevent burns; monitor/document location, size and treatment of wound, and report abnormalities, failure to heal, signs and symptoms of infection, maceration (softening of the skin which occurs when skin is in contact with moisture for too long) etc. to the physician. Review of the skin/wound note dated 03/05/24 timed 10:14 A.M. revealed Resident #39 was seen by the wound team. The note indicated the right anterior thigh burn was healing. The burn wound measured 6.5 cm length by 3.6 cm width with 0.1 cm depth with 100 percent epithelial tissue. There was no exudate or signs/symptoms of infection. Treatment included cleaning the wound with Dial antibacterial soap, applying Xeroform (petroleum based gauze), covering with ABD (large padded gauze dressing) and placing tape on edges to keep ABD in place. Nursing was to continue to offload pressure. Review of the March 2024 physician orders revealed active orders to clean the right anterior thigh with Dial antibacterial soap, apply Xeroform, cover with ABD, place tape on edges to keep ABD in place every dayshift and every 24 hours as needed for burn. Interview on 03/05/24 at 4:58 P.M. with Resident #39 revealed at the time of the incident on 01/29/24, she had not been feeling well and had not eaten much for a couple of days. Resident #39 wanted soup and asked one of the aides to warm up the soup for her. Resident #39 was in bed and spilled the soup on herself as she was trying to eat the soup. There were two STNAs in room and one STNA left the room. Resident #39 thought the STNA left the room to get the nurse; however, the nurse did not come. Resident #39 thought they were busy and had forgotten about her. Resident #39 said STNA #449 was the STNA that stayed in the room with her and STNA #449 put barrier cream on the burn which helped to cool it down and soothe the pain. When Resident #39 woke up the next morning the skin had welted up. Resident #39 stated she did not see a nurse the night the burn occurred but saw a nurse with the wound physician the next day on 01/30/24. Resident #39 did not know the name of the STNA that brought her the soup, but the STNA came back to her room that next day (01/30/24) and apologized for making the soup too hot. Resident #39 did not think the STNA worked at the facility any longer because she had not seen her since then. Resident #39 stated the burn was still healing and there was a bad scar. Interview on 03/05/24 at 5:22 P.M. with STNA #449 revealed she was not in the room when Resident #39 spilled the soup onto herself and was not the STNA who brought her the soup. STNA #449 stated she saw the burn a few hours later on 01/29/24 sometime between 7:00 P.M. and 8:00 P.M. while changing Resident #39. STNA #449 asked Resident #39 what happened, and she told her she had spilled soup onto herself. STNA #449 put barrier cream on the area and then reported it to one of the nurses working that evening but was not sure which nurse she had told. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 14 of 22 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 03/07/2024 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 0689 Level of Harm - Actual harm Residents Affected - Few Interview on 03/06/24 at 2:48 P.M. with Wound Nurse (WN) #363 revealed on 01/30/24, while she was making wound rounds, the nurse reported Resident #39 had a burn wound. WN #363 contacted the night nurse from 01/29/24 via phone to see why it had not been reported that night. The night nurse told her she was not aware that it happened. WN #363 stated she thought Resident #39 did not tell anyone what happened because she did not want to get the STNA in trouble. WN #363 stated the STNA who warmed up the soup never came back to work and did not provide a statement. WN #363 stated Resident #39's burn was massive, and she was more worried about treating the burn. WN #363 described the burn wound as one large intact blister. WN #363 said Resident #39 did not complain of pain and had stated she was okay. WN #363 stated it was okay STNA #449 applied barrier cream because it had a Vaseline base. WN #363 said she educated staff on reporting because the burn was not reported timely. WN #363 stated she was glad they caught it on the day of wound rounds because treatments were put in place. Follow-up interview on 03/06/24 at 3:45 P.M. with STNA #449 revealed she did not remember what the burn on Resident #39's thigh looked like when she first saw it on 01/29/24. STNA #449 stated maybe it was a little burn that night but she remembered seeing it the next day and it was bigger and puffier due to the blistering. Follow-up interview on 03/07/24 at 9:52 A.M. with Resident #39 revealed she could not wear pants because of the bandage covering the burn. Resident #39 stated she was not in pain but wearing pants would pull the bandage off. Resident #39 was observed up in her wheelchair with a blanket covering her lower extremity. Resident #39 pulled the blanket back revealing a large white bandage on the top portion of Resident #39's right thigh, lap area. The facility did not provide evidence of education or in-services regarding heating foods or reporting injuries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 15 of 22 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 03/07/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, interview, and policy review the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected two residents (#55 and #221) of five residents (#55, #77, #80, #92, and #221) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The facility census was 111. Findings Include: 1. Review of the medical record for Resident #55 revealed an admission date of 05/21/19. Diagnoses included disorder of central nervous system, quadriplegia, anoxic brain injury, delusional disorders, traumatic brain injury, mood disorder, and anxiety disorder. Review of the Pharmacist's Recommendation to Prescriber form dated 02/16/23 revealed Resident #55 was currently receiving Lexapro 20 milligrams (mg) daily. The form indicated within the first year in which a resident was admitted on a psychotropic medication or after the prescribing practitioner had initiated a psychotropic medication, the facility must attempt a gradual dose reduction (GDR) in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. A GDR could be contraindicated for reasons that included but were not limited to the resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; and the physician had documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. The form further indicated if appropriate, consider a GDR at this time. If not appropriate, please document rationale for contraindication. At the bottom of the form was a line drawn in the box next to agree, and handwritten was decrease Lexapro to 10 mg verbal order and the Director of Nursing's signature and date of 05/04/23. Review of the Pharmacist's Recommendation to Prescriber form dated 01/22/24 revealed Resident #55 had orders written 07/14/23 for Claritin 10 mg every day for allergies and Flonase every day for allergies. The form further indicated to re-evaluate the continued use of these medications, perhaps decreasing, discontinuing, or changing to as needed (prn), if appropriate. Change to prn was handwritten at the bottom of the form. The form was signed and dated by the nurse practitioner on 03/04/24. Review of the March 2024 physician orders revealed active orders for Lexapro oral tablet 10 mg, give 10 mg by mouth one time a day with an order date of 05/04/23; Claritin oral tablet 10 mg, give 10 mg by mouth every 24 hours as needed for allergies with an order date of 03/06/24, and Flonase allergy relief nasal suspension 50 microgram/activation, give two sprays in both nostrils every 24 hours as needed with an order date of 03/06/24. Interview on 03/07/24 at 2:45 P.M. with the Director of Nursing verified the pharmacy recommendations were not addressed timely and she expected the pharmacy recommendations to be addressed with 14 days. Review of the facility policy Pharmacy Recommendations revised January 2020 revealed the Director of Nursing (DON) or Assistant Director of Nursing would review the recommendations with the physician and medical director as soon as practical. The DON would track recommendations and ensure any changes were implemented into the medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 16 of 22 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 03/07/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #221 revealed an admission date of 10/26/22. Diagnoses included dementia with behavioral disturbance, psychosis, delusional disorders, hypertension, and schizoaffective disorder. Review of the Pharmacist's Recommendation to Prescriber form dated 04/26/23 revealed Resident #221 received a beta blocker -Toprol XL (Metoprolol extended relief) which required regular monitoring of blood pressure and pulse. Due to the fact that the medication was known to cause bradycardia (low heart rate), it was recommended that Resident #221's pulse be checked prior to each dose and held if heart rate (HR) was less than 60 beats per minute (bpm). The form further indicated to consider updating vitals to include the holding parameter of hold for HR less than 60 bpm to the order. On the bottom of the form there was a handwritten slash through the agree check box and it was signed by the nurse practitioner and dated 06/07/23. Review of the June 2023 Medication Administration Record (MAR) revealed an order for Metoprolol succinate extended release tablet 24 hour 50 mg, give one tablet by mouth two times a day for hypertension, hold for HR less than 60 bpm with a start date of 06/26/23. The order was later discontinued on 10/25/23. Review of the Pharmacist's Recommendation to Prescriber form dated 01/22/24 revealed Resident #221 had an as needed (prn) order for the psychotropic medication, lorazepam 0.5 milligram (mg) every four hours prn. The form further indicated that per the Centers of Medicare and Medicaid Services (CMS) prn psychotropic medications were limited to 14 days. If use was beyond 14 days, the rationale and estimated duration of use had to be documented. In the handwritten selection portion of the form it indicated to add a three months stop date which was signed by the nurse practitioner on 03/04/24. Review of the March 2024 physician orders revealed active orders for Ativan (lorazepam) oral tablet 0.5 mg, give 0.5 mg by mouth every four hours as needed for agitation for three months with an order date of 03/06/24. Interview on 03/07/24 at 2:45 P.M. with the Director of Nursing verified the pharmacy recommendations were not addressed timely and she expected the pharmacy recommendations to be addressed with 14 days. Review of the facility policy Pharmacy Recommendations revised January 2020 revealed the Director of Nursing (DON) or Assistant Director of Nursing would review the recommendations with the physician and medical director as soon as practical. The DON would track recommendations and ensure any changes were implemented into the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 17 of 22 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 03/07/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to ensure a rationale for extending an as needed psychotropic medication beyond 14 days was documented in the resident's medical record and failed to monitor for side effects of psychotropic medication use. This affected one resident (#221) of five residents (#55, #77, #80, #92, and #221) reviewed for unnecessary medications and psychotropic medications. The facility census was 111. Findings Include: Review of the medical record for Resident #221 revealed an admission date of 10/26/22. Diagnoses included dementia with behavioral disturbance, psychosis, delusional disorders, hypertension, and schizoaffective disorder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #221 had severely impaired cognition, had physical behaviors during one to three days of the seven day look back period, and received antipsychotic medications routinely. Review of the plan of care dated 01/19/24 revealed Resident #221 used the anti-anxiety medication Ativan related to anxiety. Interventions included giving anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. Antianxiety side effects included drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Paradoxical side effects included mania, hostility, and rage, aggressive or impulsive behavior, and hallucinations. Review of the plan of care dated 01/19/24 revealed Resident #221 used the psychotropic medication Zyprexa (olanzapine) for treatment of Schizophrenia/Schizoaffective Disorder. Intervention included monitor/record/report to the physician as needed any side effects and adverse reactions of psychoactive medications which included unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Review of the Pharmacist's Recommendation to Prescriber form dated 01/22/24 revealed Resident #221 had an as needed (PRN) order for the psychotropic, lorazepam (Ativan) 0.5 milligram (mg) every four hours PRN. Per the Centers of Medicare and Medicaid Services (CMS), PRN psychotropic medications were limited to 14 days. If use was beyond 14 days, the rationale and estimated duration of use must be documented. The form indicated to add three month stop date which was signed by the nurse practitioner on 03/04/24. Review of the March 2024 physician orders revealed active orders for Ativan oral tablet 0.5 mg, give 0.5 mg by mouth every four hours as needed for agitation for three months with an order date of 03/06/24 and a stop date of 06/06/24. An active order for olanzapine tablet 2.5 mg, give one tablet by mouth two times a day for schizoaffective disorder with an order date of 01/05/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 18 of 22 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 03/07/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident #221's medical record revealed no documented rationale to extend the lorazepam 0.5 mg PRN beyond 14 days and there was no documented monitoring of side effects for the use of the olanzapine 2.5 mg. Review of the facility policy Antipsychotic Medication Use revised April 2007 revealed nursing staff were to monitor and report side effects to the attending physicians including sedation, orthostatic hypotension, light headedness, dry mouth, blurred vision, constipation, urinary retention, increased psychotropic symptoms, extrapyramidal effects, akathisia, dystonia, tremor, rigidity, akinesia, or tardive dyskinesia. Interviews on 03/07/24 at 2:45 P.M. and 3:03 P.M. with the Director of Nursing verified the nurse practitioner did not document a rationale as to why she extended the PRN lorazepam beyond 14 days and verified there was no evidence Resident #221 was monitored for side effects of olanzapine or lorazepam. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 19 of 22 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 03/07/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to provide meals according to preferences and/or food allergies. This affected one (Resident #37) of five residents observed for meals. Findings Include: Review of medical record for Resident #37 revealed an admission date of 11/11/21. Diagnoses included chronic obstructive pulmonary disease and chronic kidney disease. The resident had intact cognition. Review of the nutritional assessment dated [DATE] revealed Resident #37 had allergies to asparagus, mint, apples, and intolerance to dairy. Resident #37 stated allergy to eggs was not an allergy. Interview on 03/04/24 at 9:30 A.M. with Resident #37 revealed staff brought him food that he was allergic to. Resident #37 stated he could only eat egg whites because regular eggs made his throat feel funny and he could not have milk. Resident #37 stated he kept telling staff that he could not eat regular eggs and milk but staff kept serving him scrambled eggs and whole or two percent milk. Observation on 03/06/24 at 8:28 A.M. revealed Resident #37 was served French toast, egg whites, sausage, and whole milk. Review of the meal ticket dated 03/06/24 revealed Resident #37 had an allergy to apples and mint and was to receive egg whites only. The ticket did not indicate the resident had a milk intolerance. Observation and interview immediately after the above observation with Licensed Practical Nurse #445 verified Resident #37 was served French toast and whole milk. Interview on 03/06/24 at 8:40 A.M. with [NAME] #384 revealed she was aware of Resident #37's allergies and served the resident regular toast, egg whites and lactate milk. [NAME] #384 was asked how she prepared the French toast, she stated she dipped the toast in whole eggs and added cinnamon and brown sugar before frying. Review of the facility policy titled Food Allergies and Intolerances, dated 2008 revealed residents would be assessed for a history of food allergies and intolerances upon admission. All resident reported allergies and intolerances would be documented in the assessment notes and care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 20 of 22 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 03/07/2024 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, interview, and record review the facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerators. This had the potential to affect all residents except three residents (#6, #19, and #50) who received nothing by mouth. The facility census was 111. Findings Include: Observations on 03/04/24 from 8:00 A.M. to 8:18 A.M. during a tour of the kitchen revealed on the bottom shelf of the prep table across from the walk-in freezer table there was a clear container of bulk sugar with a silver scoop stored inside of it. The blue lid of the sugar container was dirty with food debris, and the shelf itself had various food debris, crumbs, and grease. Behind the prep table there was a silver pipe that ran along the wall which had various food debris and crumbs on it. There was various food debris and crumbs on the floor behind the prep table. Observation of the walk-in cooler revealed a large stain on the floor under the rack next to the door and various food debris, crumbs, small juice containers, and liquid spillage on the floor. Interview with Dietary [NAME] (DC) #348 on 03/04/24 between 8:00 A.M. and 8:18 A.M., during the tour of the kitchen, verified the findings. Follow-up observation of the kitchen on 03/05/24 at 9:58 A.M. revealed near the fryer and stove area, the grout on the floor was heavily dirty, and what appeared to be a drain in the floor was heavily dirty with a built up black substance and debris. The wall near the fryer was missing several tiles and appeared dirty with dried grease and food splatter. Observation of the reach-in cooler near the stove revealed various food crumbs and tannish colored spillage. Interview, at the time of the observation, with Certified Dietary Manager (CDM) #447 verified the observations and stated they attempted to power wash the area near the fryer and some of the tiles started to come off. Observations on 03/05/24 from 10:02 A.M. to 10:14 A.M. of the nursing unit refrigerators with CDM #447 revealed the first floor refrigerator was cluttered and had various food debris inside the refrigerator. Observation of the second floor nursing unit refrigerator revealed various food debris on the outside and inside of the refrigerator. Observation of the third floor refrigerator revealed various food debris inside of the refrigerator. Interview on 03/05/24 between 10:02 A.M. and 10:14 A.M. with CDM #447 verified the findings. Review of the facility Sanitation policy revised December 2008 revealed the food service area would be maintained in a clean and sanitary manner. Review of a list provided by the facility revealed Residents #6, #19, and #50 received nothing by mouth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 21 of 22 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 03/07/2024 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 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm Observation on 03/04/24 at 12:12 P.M. revealed the handrail was broken by the women's tub room on the second floor that was under construction. Residents Affected - Some Observation on 03/04/24 at 12:12 P.M. revealed the handrail was broken by Resident #9's room. Observation and interview on 03/04/24 at 12:31 P.M. with Licensed Practical Nurse #302 verified broken handrails by Resident #9's room and the women's tub room that was under construction. Review of the census provided by the facility revealed Residents #2, #5, #9 #11, #17, #22, #25, #28, #29, #31, #32, #33, #35, #39, #40, #42, #43, #45, #47, #50, #53, #54, #55, #56, #59, #66, #68, #70, #72, #73, #75, #84, #85, #87, #90, #94, #97, #98, #99, #100, #105, #106, #107, #109, #110, #118, #119, #120 resided on the second floor. Based on observation and interview the facility failed to ensure handrails were securely affixed to the walls. This had the potetntial to affect all 48 residents that resided on the second floor (#2, #5, #9 #11, #17, #22, #25, #28, #29, #31, #32, #33, #35, #39, #40, #42, #43, #45, #47, #50, #53, #54, #55, #56, #59, #66, #68, #70, #72, #73, #75, #84, #85, #87, #90, #94, #97, #98, #99, #100, #105, #106, #107, #109, #110, #118, #119, #120). The facility census was 111. Findings Include: Observation on 03/04/24 at 12:11 P.M. revealed the handrail located in the hallway outside of Resident #55 and Resident #75's room was not completely attached to the wall. Interview on 03/04/24 at 12:33 P.M. with State Tested Nurse Aide (STNA) #373 verified the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 22 of 22