Inspection·April 22, 2024

F 0689 holder, and supervision. Plan of care was initiated to assure the resident was safe while smoking. Level of Harm - Actual harm Review of the Current Designated Smoking Times revealed the facility smoking times were established for 9:00 A.M., 11:00 A.M., 2:00 P.M., 4:00 P.M., 7:00 P.M. and 9:00 P.M. Residents Affected - Few Observation on 04/12/24 at 9:50 A.M., while walking through the dining room on the first floor with Dietary Technician #370, revealed Resident #31 was sitting in the dining room next to Resident #76. Resident #31 had a smoking apron on. Resident #31 did not have a cigarette holder in her hand and was observed actively smoking a cigarette in the dining room. Dietary Technician #370 instructed Resident #31 she needed to go outside to smoke. Business Office Human Resource (HR) Manager #288 walked by as Resident #31 began to go out the exit door into the courtyard and HR Manager #288 stated, Yea, I am supposed to go out with her. HR Manager #288 confirmed Resident #31 was to have supervision while smoking and confirmed residents were not to smoke in the facility. Interview on 04/12/24 at 10:00 A.M., with the Administrator revealed he was already made aware Resident #31 was smoking in the dining room. The Administrator confirmed residents were not to smoke in the facility. Interview on 04/12/24 at 11:33 A.M. with HR Manager #288 revealed Resident #76 lit the cigarette in the dining room for Resident #31. HR Manager #288 revealed she didn't know if residents were allowed to keep their cigarettes and lighters on them. HR Manager #288 stated she just fills in sometimes for staff and monitors/supervises residents on their smoke breaks. Observation and interview on 04/12/24 at 12:46 P.M. with Licensed Practical Nurse (LPN) #313, revealed staff were supposed to keep resident's cigarettes and lighters locked up in the utility room or downstairs on a cart. LPN #313 revealed there were independent residents who could smoke anytime but they were to ask for the cigarette and lighter each time then return them when done. There were also residents who were unsafe to smoke independently and required staff go out with them at designated smoking times. LPN #313 stated Resident #31 was unsafe to smoke independently as her left hand was contracted. Observation of Resident #31's right hand with LPN #313 revealed Resident #31 had multiple scarred areas on the inner portions of the right index finger and middle finger. There was one large fluid filled blister on the right index finger near the nail bed and one fluid filled double blister on the inner middle finger between the first and second knuckle. LPN #313 revealed she did not know the blisters were there. When LPN #313 asked Resident #31 what happened, Resident #31 did not verbally respond. Resident #31 looked down and did not look back at the surveyor or nurse. LPN #313 confirmed Resident #31 was alert and oriented but was unsafe to smoke by herself. Interview on 04/12/24 at 1:36 P.M. with Wound Care Nurse Registered Nurse (RN) #265 revealed Resident #31 was a smoker. Wound Care Nurse RN #265 revealed she had noticed blisters on her hands before, from smoking. The blisters healed badly due to repetitive smoking and burning her fingers repetitively. Resident #31 was supposed to be using the smoking apron and extender to prevent burning her fingers. Resident #31 often just sat all day in the dining room. Wound Care Nurse RN #265 revealed they don't treat the blisters on Resident #31's fingers because they were not infected so she would not have received any treatment orders. Review of Resident #31's progress notes for March and April 2024 revealed no documentation of blisters or scars on Resident #31's fingers. Wound Care Nurse RN #265 confirmed there was no documentation she could find from admission of Resident #31 burning her fingers or having scars or blisters on her fingers and confirmed she had personally seen them on many occasions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 2 of 8 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 04/22/2024 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 04/12/24 between 3:23 P.M. and 4:07 P.M. with the Director of Nursing (DON) confirmed Resident #31 required supervision while smoking. The DON stated residents were not to smoke inside the facility. Cigarettes and lighters were to be kept locked up for all residents, independent residents could go outside anytime but they were required to return the cigarettes and lighters after each time they smoked. Residents who required supervision had designated times to smoke. The DON revealed the staff delegated to supervise smokers included herself, HR, activity personnel, nursing staff and the social worker. The DON verified the last skin assessment completed for Resident #31 in the medical record was dated 03/19/24 which revealed no new areas. The DON confirmed skin assessments were to be completed weekly. 2. Review of Resident #71's medical record revealed an admission date of 01/17/23. Diagnoses included diabetes mellitus, muscle weakness, cognitive communication deficit, need for assistance with personal care, and tobacco use. Review of the annual MDS assessment dated [DATE] revealed Resident 71 was cognitively intact. Resident #71 used a wheelchair for mobility, required set up or clean up assist with eating, toileting, independent with dressing and personal hygiene. Review of the care plan for Resident #71 revealed no care plan was in place for smoking. Review of the paper form titled Smoking Assessment for Resident #71 dated 01/22/24 revealed Resident #71 was an independent smoker. Observation on 04/12/24 at 10:42 A.M., revealed Resident #71 was in the dining room on the first floor smoking a lit cigarette. Observation revealed no staff were within sight of the area. Resident #66 was sitting near Resident #71 and both Residents #71 and #66 confirmed Resident #71 was smoking a cigarette in the dining room. Resident #71 revealed she was getting ready to go outside then exited the facility through the door, located in the dining room into the courtyard. Observation on 04/12/24 at 10:44 A.M. revealed the Administrator was in his office. The surveyor informed the Administrator, Resident #71 was observed in the dining room smoking a cigarette. The Administrator stated, Well, I guess I am going to need to put someone in there. Interview on 04/12/24 at 4:07 P.M. with the DON revealed Resident #71 was an independent smoker. The DON confirmed Resident #71 did not have a care plan for smoking. 3. Review of Resident #76's medical record revealed an admission date of 11/22/23. Diagnoses included heart failure, muscle weakness and difficulty in walking. Review of the quarterly MDS assessment dated [DATE] revealed Resident #76 was cognitively intact. Resident #76 used a wheelchair for mobility, was independent for eating, toileting, dressing and personal hygiene. Review of the care plan for Resident #76 revealed no care plan was in place for smoking. Review of the resident assessments revealed no smoking assessment was completed for Resident #76. Interview and observation on 04/12/24 at 12:22 P.M., revealed Resident #76 was sitting in the dining room on the first floor. Resident #76 took his cigarettes and lighter out of his pants pockets. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 3 of 8 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 04/22/2024 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 Resident #76 stated some residents cannot light their own cigarettes, so he does it for them. Resident #76 stated, No one ever told me I couldn't keep my cigarettes and lighter or couldn't help others light their cigarettes. Interview on 04/12/24 at 3:52 P.M. with Activities Director #322 revealed Resident #76 was an unsupervised smoker, he could go outside to the smoking area whenever he wanted, and he has his own lighter and cigarettes he can carry them and keep them himself. Interview on 04/12/24 at 4:07 P.M. with the DON revealed once a resident was admitted , they did a 72-hour care conference and determined if the resident was a smoker. The DON revealed then either herself, the Unit Manager, Charge Nurse, or the Social Worker would do a smoking assessment at that time. The DON revealed she did not know Resident #76 currently smoked cigarettes. Resident #76 had prior surgery and the doctor said he should not smoke. She did not know he was smoking but revealed she knew he used to. The DON confirmed Resident #76 did not have a smoking assessment or care plan completed for smoking. Interview on 04/12/24 at 4:20 P.M. with Resident #76 revealed he smoked cigarettes the whole time he had been at the facility and nobody ever asked him if he smoked. Interview on 04/12/24 at 4:32 P.M. with LPN #313 confirmed she was Resident #76's charge nurse. LPN #313 revealed Resident #76 was an independent smoker, and he had always smoked. LPN #313 revealed she did not know if Resident #76 had his own cigarettes and lighter, but she did know he smoked. Observation on 04/12/24 at 4:35 P.M. revealed Resident #76 was sitting outside in the smoking area smoking independently. No staff was present. Review of the policy titled, Smoking, revised 01/02/24, revealed upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, smoking times, and the extent to which the facility can accommodate their smoking preferences. Residents will be evaluated upon admission and routinely to determine if he or she is able to smoke without supervision per the smoking assessment. Residents who require supervision shall have the supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. Smoking is only permitted in designated smoking areas. Residents who require supervision must store smoking materials with staff except under supervision. Residents who do not require supervision when smoking must store smoking materials, with staff, secured on their person or in a locked container. Residents are not permitted to supervise, assist other residents with smoking, or give smoking materials to other residents. Smoking inside of the building, such as in common areas of the facility or in resident rooms is strictly prohibited. The following deficiency is based on incidental findings discovered during the course of this complaint investigation and represents continued noncompliance from the 03/07/24 survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 4 of 8 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 04/22/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, staff interview, and review of the dietary staffing schedule, the facility failed to provide sufficient staff to meet the dietary needs of the residents. This had the potential to affect all residents, except Resident #25, #89, and #90, who received nothing by mouth (NPO). The facility census was 109. Findings include: Observation of the breakfast tray line on 04/12/24 at 9:11 A.M., revealed the resident's breakfast was being served in Styrofoam containers with Styrofoam cups. Dietary [NAME] #294 revealed all residents were getting Styrofoam because there was no staff, all the scheduled kitchen staff called off except for her. Observation revealed Business Office Human Resource (HR) Manager #288, Maintenance Director #278, Central Supply #367, Speech Therapist #371, and Director of Activities #322 were on the tray line. No other Dietary staff was observed. Dietary [NAME] #294 was made aware to provide a test tray which would be the last tray served placed on the last cart served. Dietary [NAME] #294 revealed she was unable to test the food on the test tray with the surveyor because she did not have enough time. Dietary [NAME] #294 revealed the Dietary Manager was off work for a while and was working from home. Interview on 04/12/24 at 2:01 P.M., with Dietary [NAME] #294 confirmed the lunch meal was served on Styrofoam also for all residents. Dietary [NAME] #294 revealed they used Styrofoam containers to serve residents their meals when there was low staff. Dietary [NAME] #294 revealed the dietary department had no backup staff when people called off. The dietary department required three to four Dietary Aids per shift. For the dinner meal, one Dietary Aid agreed to come in and one [NAME] was scheduled, but that meant she would need to stay over. Dietary [NAME] #294 confirmed for the lunch meal, the same Department Heads assisted in the kitchen. Interview on 04/12/24 at 3:08 P.M., with HR Manager #288 confirmed the staffing for Dietary Aids in the kitchen was to be three to four Dietary Aids per shift. Review of the Dietary staffing schedule with HR Manager #288 confirmed for April 2024: There were 0 days first shift had four Dietary Aids. On 04/01/24, the first shift only had two Dietary Aids. On 04/03/24, the second shift only had two Dietary Aids. On 04/06/24, the first shift only had two Dietary Aids, second shift only had one Dietary Aid. On 04/11/24, first shift only had two Dietary Aids This deficiency represents non-compliance investigated under Complaint Number OH00152244. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 5 of 8 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 04/22/2024 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, staff interview, resident interviews, and testing of a test tray, the facility failed to ensure food was served that was visually pleasurable and palatable. This had the potential to affect all residents except Resident #25, #89, and #90 who received nothing by mouth (NPO). The facility census was 109. Residents Affected - Many Findings include: Observation and interview on 04/11/24 at 12:22 P.M., revealed Resident #33 was sitting in his room with his lunch tray in front of him. Resident #33 was not eating. Resident #33 revealed the food was horrible and it tasted the same way it looked. Observation of Resident #33's lunch tray revealed an unidentifiable main entrée, carrot squares, a roll and juice. Interview on 04/11/24 between 12:55 P.M. and 4:19 P.M., with Residents #47, #76, and #98 revealed the food was not edible, they had too much pasta, and the food did not taste good. Interview on 04/12/24 between 8:36 A.M. and 4:37 P.M., with Resident #44, #46, #47, #85, #102, #105, and #107, revealed they never liked the way their food tasted, it was horrible, gross, it did not look right, and the food did not taste good. Resident #44, #46, #85, #102, #105, and #107, revealed some days their food and drinks were served in Styrofoam containers, Resident #44, and #47 revealed they preferred regular plates. Observation of the breakfast tray line on 04/12/24 at 9:11 A.M, revealed the residents' breakfast was being served in Styrofoam containers with Styrofoam cups. Dietary [NAME] #294 revealed all residents were getting Styrofoam because there was no staff, all the scheduled kitchen staff called off except for her. Review of the menu served included cream of rice, quiche, toast, jelly, and margarine. Dietary [NAME] #294 revealed the quiche consisted of liquid eggs topped with green peppers, the facility had not used regular eggs in three years and nothing else would be added. Dietary [NAME] #294 was made aware to provide a test tray which would be the last tray served placed on the last cart served. Observation revealed three of the four pans used to cook the quiche had a thick layer of burnt brown quiche stuck to the bottom. Dietary [NAME] #294 revealed the quiche was burnt because she had to bake them in the oven because there was no steamer. Dietary [NAME] #294 revealed she was unable to test the food on the test tray with the surveyor because she did not have enough time. Dietary [NAME] #294 revealed the Dietary Manager was off work for a while and was working from home. Observation on 04/12/24 at 9:43 A.M., revealed the last resident tray was served. The test tray was temped and tasted with Dietary Tech #370. The quiche had a rubbery texture and there was no flavor of egg, only a flavor of cooked green pepper. Dietary Tech #370 confirmed she could not taste any egg, only green pepper. The toast was slightly cooked on one side, the opposite side was not cooked, and the bread was room temperature. The cooked rice cereal had no flavor at all and had a mush, pastie texture. The meal was not pleasurable to taste or appearance. Observation on 04/12/24 at 12:06 P.M., of the lunch tray line revealed the lunch meal was also being served in Styrofoam containers and cups. Interview on 04/12/24 at 2:01 P.M., with Dietary [NAME] #294 confirmed the lunch meal was served on Styrofoam also for all residents. Dietary [NAME] #294 revealed they used Styrofoam containers to serve residents their meals when there was low staff. Dietary [NAME] #294 revealed the toaster was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 6 of 8 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 04/22/2024 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 working right and confirmed it only toasted one side of the bread. Level of Harm - Minimal harm or potential for actual harm Interview on 04/12/24 at 4:07 P.M., with Director of Nursing (DON) stated, We hear complaints of food all the time, but it's about preference. Residents Affected - Many This deficiency represents non-compliance investigated under Complaint Number OH00152313. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 7 of 8 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 04/22/2024 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. This had the potential to affect all residents except Resident #25, #89, and #90 who received nothing by mouth (NPO). The facility census was 109. Findings include: Interview on 04/12/24 at 9:32 A.M., with Dietary [NAME] #294 revealed she did not have time to observe the refrigerators with the surveyor. Observation and interview on 04/12/24 at 9:33 A.M., of the walk-in refrigerator with Business Office Human Resources (HR) Manager #288 revealed a large container of partially used potato salad was undated, a partially used container of macaroni and hamburger had no date, multiple preset salads and puddings were on three shelves in small containers, none had dates. There were two large containers of partially used salad dressings with no date. There were large stacks of opened cheese, none were dated. Under the wire racks of food on the floor there were large spills that included food particles and dried multicolored liquid. HR Manager #288 verified the undated food products and the spills on the floor. Observation of the small refrigerator (located on the other side of the kitchen) with HR Manager #288 revealed Dietary [NAME] #294 was actively dating the food items in the refrigerator as the surveyor approached. Dietary [NAME] #294 verified she was dating the food items in the small fridge and revealed, I told the staff last night to do it, they didn't so yes that's what I am doing. Items not yet dated included four premade cheese sandwiches, multiple partially used stacks of cheese, a container of partially used liquid eggs, and a wrapped portion of a pizza. Dietary [NAME] #294 revealed she did not remember which of the other multiple food items (that were in facility metal containers and covered in saran wrap) she just dated. Review of the policy titled, Food Receiving and Storage, revised December 2008, revealed Food Services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled, and dated use by date. This deficiency represents non-compliance investigated under Complaint Number OH00152313 and the continued non compliance from the survey 03/07/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365215 If continuation sheet Page 8 of 8