Health inspection·November 13, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to report an allegation of misappropriation for Resident #86. This affected one resident (#86) of three residents reviewed for reporting of abuse or misappropriation. The census was 83. Findings include: Review of the medical record for Resident #83 revealed an admisison date of 06/16/23 and a discharge date of 08/09/23. Diagnoses included automatice dysreflexia, quadriplegia c1-c4 incomplete and neuromuscular dysfunction of bladder. Reivew of medical record revealed no inventory list of personal belongings. Interview on 10/31/23 at 3:32 P.M. with Administrator and Director of Rehab/Administrator in Training (DOR/AIT) #240 revealed they did not report misappropriation when Resident # 86 stated he was missing items after he had been discharged to the the hospital then subsequently another facility. They stated he did not accuse the facility of stealing the items plus he was already discharged therefore they did not believe it was necessary to make a self-reported incident. The Administrator stated a policeman came to the facility on [DATE] to discuss a report Resident #86 made. The Administrator did not believe it was necessary to make a self-reported incident at that time either as she believed they sent everything he had to the other facility with their driver. At a subsequent interview on 10/31/23 the Administrator stated she initiated a self-reported incident for misappropriation on this date. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021 revealed the facility should report and investigate in a timely manner. This deficiency represents non-compliance investigated under Complaint Number OH00147110 and Complaint Number OH00147037. 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 3 Event ID: 365845 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 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)