Inspection·September 27, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to timely report and investigate a resident incident. This affected one (Resident #76) of three residents reviewed for incidents. The census was 112. Findings Include: Resident #112 was admitted to the facility on [DATE]. Her diagnoses were cerebral infarction, dysarthria and anarthria, cognitive communication deficit, need for assistance, difficulty in walking, cerebral infarction, end stage renal disease, obstructive sleep apnea, hypertensive chronic kidney disease (stage V), chronic embolism and thrombosis, congestive heart failure, type II diabetes, hypothyroidism, morbid obesity, anemia, and hemiplegia and hemiparesis. Review of her minimum data set (MDS) assessment, dated 09/14/24, revealed she was cognitively intact. Review of Resident #112 occupational therapy notes, dated 08/20/24 but not written until 08/27/24, revealed patient complete opposition exercises, table top activities for grasp, heat with passive range of motion. Patient let go of two pound free weight and it rolled down leg and therapist tried to push away. Therapist asked if she was ok, and did not state she was having pain. Review of Resident #112 medical records, including progress notes, care plans, skin assessments, and investigation documentation, dated 08/20/24 to 08/22/24, found no evidence that this incident/accident was reported to the nursing staff or that a full assessment of Resident #112 leg was completed to ensure no injury was present. Review of Resident #112 progress notes, dated 08/23/24, revealed a nurse spoke with the facility physician and received an order for x- ray of Resident #112 left ankle. This was in response to Resident #112 complaining of left ankle/foot pain, level eight out of ten. Review of Resident #112 x-ray documentation, dated 08/23/24, revealed on 08/23/24, there is a nondisplaced fracture noted of the distal tibia of unknown acuity. The ankle mortise and talar dome appear normal. There is soft tissue swelling. Recommended clinical correlation. Axial imaging may be performed for further evaluation. Review of Resident #112 orthopedic appointment documentation, dated 08/29/24, revealed Resident #112 did not have a fracture but soft tissue injury; she was ordered to wear a boot and return for observation/review in one month. (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 2 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 09/27/2024 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)