Inspection·September 4, 2024

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 observation, interview and record review the facility failed to provide adequate mouth care for dependent residents. This affected two (#22 and #88) of two residents observed for mouth care. The facility census was 112. Residents Affected - Few Finding include: 1. Review of Resident #22's medical records revealed an admission date of 04/27/20. Diagnoses included stroke with left sided weakness, paraplegia and respiratory failure. Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was dependent for mouth care, bathing and personal hygiene. Review of Resident #22's care plan dated 07/10/24 revealed Resident #22 had self care performance deficits related to paraplegia. Interventions included provide mouth care every shift and as needed. Observation on 09/03/24 at 9:01 A.M. of Resident #22 with the Assistant Director of Nursing (ADON) revealed Resident #22's mouth and lips were dry and cracked and Resident #22 had skin hanging from his lips. ADON confirmed Resident #22 required mouth care from staff due to his dry and cracked lips and stated mouth care should be completed daily. Resident #22 was not interviewable. Review of facility's undated policy Activities of Daily Living revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently including oral hygiene. 2. Review of Resident #88's medical records revealed an admission date of 12/27/23. Diagnoses included quadriplegia, traumatic brain injury and muscle weakness. Review of Resident #88's MDS assessment dated [DATE] revealed Resident #88 was rarely understood. Resident #88 was dependent for mouth care, bathing and personal hygiene. Review of Resident #88's care plan dated 07/23/24 revealed Resident #88 had oral problems related to poor oral hygiene. Interventions included provide mouth care per activities of daily living (ADLs). Observation on 09/03/24 at 12:41 P.M. of Resident #88 with the ADON revealed Resident #88's top lip was stuck to his upper teeth and his mouth was dry and lips were cracked. Resident #88 had a large amount of plaque build up on his upper and lower teeth. The ADON confirmed Resident #88 required (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365215 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2024 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)