Health inspection·March 19, 2024

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, interview, self-reported incident (SRI) review and policy review, the facility failed to ensure Resident #28's allegation of misappropriation was reported within 24 hours to the State agency as required. This finding affected one resident (#28) of two residents reviewed for misappropriation. Findings include: Review of a Misappropriation SRI (tracking #245238) dated 03/15/24 indicated Resident #28 went to the activity director and reported Resident #80 had taken pills from his bag a few days ago. The investigation was ongoing. Review of Resident #28's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified fracture of the left femur, encounter for other orthopedic aftercare, and unspecified cirrhosis of the liver. Review of Resident #28's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #80's medical record revealed the resident was admitted on [DATE] with diagnoses including alcoholic cirrhosis of the liver without ascites, iron deficiency anemia, and major depressive disorder. Review of Resident #80's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Interview on 03/19/24 at 8:42 A.M. with Resident #28 revealed he had reported to Certified Occupational Therapy Assistant (COTA) #821 on 03/09/24 that Resident #80 had come into his room and took a bottle of suboxone (treats narcotic dependence) tablets (28 tablets) out of his personal belongings. He stated the resident returned the bottle with 13 tablets remaining and self-administered the other 15 tablets. Interview on 03/19/24 at 9:03 A.M. with Resident #80 revealed Resident #28 gave her the suboxone to self-administer. She would not answer further questions. Interview on 03/19/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed a Misappropriation SRI (tracking #245238) was filed on 03/15/24. (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 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 03/19/2024 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)