Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Suburban Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Failure to Protect Resident From Neglect: A resident with significant medical and ADL dependence was sent to the hospital for a scheduled procedure and was found by hospital staff with caked feces, maggots on both feet, and multiple foot wounds with cellulitis. Facility records showed inconsistent documentation about bathing and shoe removal, limited evidence that refusals were tracked, and conflicting staff accounts about whether the resident had been cleaned before transfer. The hospital documented concerns for neglect, while the administrator stated the report was not treated as an allegation of neglect.
A resident with quadriplegia and total ADL dependence was placed on a toilet in a locked common bathroom and then left unattended when a CNA left the facility without notifying staff. Because the call light was not functioning, the resident had to get himself off the toilet, crawl to the door, and bang for help before staff found him on the floor hours later. He later reported wrist pain and described feeling abandoned, angry, miserable, and fearful after the incident.
A facility failed to maintain a working call light system and did not document required resident checks while the system was down. Residents were given manual bells, but many CNA attestation forms were missing, and staff interviews confirmed the checks were not consistently documented. One cognitively intact, fully dependent resident with quadriplegia was left on a toilet in a common bathroom for hours and was later found on the floor after staff gave conflicting accounts about whether a bell or call device was available.
A resident’s room was found unsanitary, with no window screen, dead bugs on the windowsill and floor, insects on the walls, and gnats in the bathroom. The resident reported bugs, mice, moths, and flies in the room, while the DMH confirmed the missing screen and observed the infestation and debris.
Care plans were not updated for two residents to reflect current needs. One resident’s coccyx pressure ulcer progressed from stage 2 to stage 3, but the care plan still only addressed potential skin breakdown and did not include the wound’s onset or treatment interventions, including EBP. Another resident with schizoaffective disorder, bipolar disorder, DM2, COPD, HTN, and obesity had a documented pattern of refusing care and keeping shoes on during bathing, yet the care plan did not address refusal of foot care or staff interventions to ensure hygiene and foot care were provided.
A resident with multiple chronic conditions had inconsistent wound documentation, with notes and orders identifying the wound on the right buttocks even though the wound was observed on the left buttocks. During wound care, an LPN verified the order but treated the left buttocks after finding no wound on the right, and confirmed the provider note, physician order, and treatment documentation were written incorrectly.
Failure to Follow EBP During Wound Care: Two residents with stage 3 wounds received wound care without the required gown use under posted EBP instructions. An LPN performed hand hygiene and wore gloves, but did not don a gown while treating open coccyx and buttocks wounds, despite EBP signs at the doorway and orders/care plans calling for EBP during wound care.
A resident with multiple chronic conditions did not receive prescribed levothyroxine and aspirin as ordered due to an oversight during the admission intake process, resulting in a significant delay in medication administration. The DON confirmed the failure to follow physician orders, which was not in accordance with facility policy.
The facility failed to properly date and store food in the kitchen, affecting 109 residents. Observations revealed undated and uncovered food items, including whipped cream, sausage patties, pudding, oatmeal, milk, shredded cheese, noodles, salad, and sandwiches. The Dietary Manager confirmed these issues, which violated the facility's food storage policy.
A resident with complex medical conditions experienced a 9.5% weight loss in one month, which was not verified or addressed by the facility. The facility's policy required confirmation of significant weight changes and notification of the dietitian and physician, but these actions were not taken, leading to a deficiency.
A resident with a complex medical history experienced an incident during occupational therapy where a dumbbell was dropped on her foot. The therapist did not report or document the incident immediately, nor was a full assessment conducted. The resident later reported significant pain, leading to an x-ray and orthopedic evaluation. The facility failed to adhere to its policy of timely reporting and assessment, resulting in a deficiency.
Two residents in the facility, both dependent on staff for oral hygiene, did not receive adequate mouth care. One resident with paraplegia was observed with dry, cracked lips, while another with quadriplegia had a dry mouth and plaque buildup. The ADON confirmed the lack of daily mouth care, contrary to the facility's policy on Activities of Daily Living.
A resident with bladder dysfunction and a history of stroke did not receive timely incontinence and catheter care, resulting in a saturated mattress pad and inadequate catheter maintenance. Observations showed dried stool and urine on the mattress pad and crusted debris around the catheter site. Staff interviews revealed a lack of awareness about the last care provided, indicating non-compliance with facility policies requiring regular catheter care.
A facility failed to provide appropriate care for a resident with a PEG tube, resulting in dark crusted debris and reddened skin around the insertion site. The resident, with conditions including dysphasia and stroke, required tube feedings and monitoring for infection. Observations revealed that the STNA did not provide PEG tube care, and the LPN had not attended to the tube on the observed date. The ADON confirmed the need for daily cleaning, highlighting a lapse in care.
The facility failed to supervise residents who required assistance with smoking, secure smoking materials, and ensure residents smoked in designated areas. One resident suffered cigarette burns due to lack of supervision, while two other residents were observed smoking inside the facility without proper assessments or care plans in place.
The facility failed to provide sufficient dietary staff, leading to meals being served in Styrofoam containers and non-dietary staff assisting in the kitchen. The dietary department had no backup staff, and the required staffing levels were not met, affecting all residents except those who were NPO.
The facility failed to ensure that food served to residents was visually pleasurable and palatable. Multiple residents expressed dissatisfaction with the quality and taste of their meals, which were often served in Styrofoam containers due to staff shortages. Observations revealed burnt and flavorless quiche, inadequately cooked toast, and flavorless rice cereal. The DON acknowledged frequent complaints about the food but attributed them to preference.
The facility failed to safely store and date food items, with multiple undated food products and spills observed in the kitchen. This non-compliance was verified by the HR Manager and a dietary cook, who admitted to dating items as the surveyor approached.
Failure to Protect Resident From Neglect
Penalty
Summary
The facility failed to protect a resident from neglect when the resident was transferred to the hospital for a scheduled procedure and hospital staff found the resident with caked feces, a maggot infestation, and multiple superficial wounds to both feet with cellulitis of the lower extremities. The resident had diagnoses including schizoaffective disorder, bipolar disorder, type 2 diabetes mellitus, COPD, hypertension, and obesity. The MDS showed the resident was cognitively intact, dependent on staff for all ADLs except eating, oral hygiene, and upper body dressing, and was always incontinent of bowel and occasionally incontinent of urine. The resident’s care plan identified resisting care and refusing toileting and incontinence care, but the record did not specifically identify refusal to remove shoes for bathing or provide interventions for bathing the feet. Progress notes documented only limited refusals, including one instance of refusing to take shoes off during wound care, one bathing refusal where the guardian was notified, and one refusal of morning care, but there was no consistent documentation that the resident refused foot bathing or shoe removal. Bath and shower documentation for April through June did not show refusals to remove shoes for bathing, and the plan of care for nursing assistant care called for shower or bed bath per resident preference and nail care on every shower day, with refusals to be documented. On the day of transfer, the resident was scheduled for a shower before transportation to the hospital, but a witness statement described the resident choosing to go outside to smoke instead of showering, with the guardian notified of the refusal and the resident leaving shortly after returning to the unit. Hospital records documented that the resident arrived in urine-soaked clothing with numerous maggots over both feet, was cleaned, and was sent to the ED for further evaluation. The ED note described feces on both feet, poor hygiene, possible cellulitis, maggot infestation, and failure to thrive. Facility staff statements and interviews showed conflicting accounts about whether the resident’s feet had been washed and whether he refused to remove his shoes, while the administrator stated the hospital report was not treated as neglect because it was not received as such. The facility’s abuse and neglect policy required prevention and identification of abuse and neglect but did not define neglect or provide staff guidance on what might constitute neglect.
Resident Left Unattended in Locked Bathroom Without Working Call Light
Penalty
Summary
The facility failed to ensure a resident was free from involuntary seclusion when he was left alone in a locked common bathroom after being placed on the toilet by a CNA. The resident had diagnoses including toxic encephalopathy, peripheral vascular disease, quadriplegia, traumatic brain injury, major depressive disorder, anxiety disorder, delusional disorder, and antisocial personality disorder. He was cognitively intact, dependent for all ADLs, used an electric wheelchair with setup assistance, and required a mechanical lift for transfers. According to the record and interviews, the resident was placed on the toilet in the common bathroom and then left unattended when the CNA left the facility without telling staff. The bathroom required a code to open, and the resident was unable to call for help because the call light system was not functioning. The resident later placed himself on the floor, crawled to the wall, and banged on it to get attention. Staff later found him on the bathroom floor near the door after he had been missing for approximately two to four hours. The resident reported that he had been left on the toilet for over four hours, that he had to push himself off the toilet and scoot to the door for help, and that he experienced pain in his wrist after crawling. A progress note documented swelling and pain in the left wrist, and an x-ray showed no acute fracture or dislocation. The resident described feeling abandoned, angry, miserable, and fearful after the incident, and the record showed no evidence that his psychosocial concerns were assessed or treated after the event. Interviews with staff were inconsistent about who assisted the resident, whether another staff member was involved, and whether the call light system was working at the time.
Failed Call Light System and Inadequate Resident Supervision
Penalty
Summary
The facility failed to maintain an adequate functioning call light system and did not follow its own plan while the system was down by providing documented resident supervision through CNA attestation statements. The call light system began malfunctioning when some resident room call lights were not showing as activated, and after an attempted reset the entire system went down. Residents were then given manual hand bells, staff were told to perform room checks at least every two hours, and CNAs were supposed to document those checks with attestations. Review of the attestations showed many CNAs did not document resident checks on multiple days between 06/01/26 and 06/14/26, and the Administrator and DON confirmed there were no CNA attestations during that period to show residents received adequate routine checks while the call system was not functioning. Resident #334 was admitted with diagnoses including toxic encephalopathy, peripheral vascular disease, quadriplegia, traumatic brain injury, major depressive disorder, anxiety disorder, delusional disorder, and antisocial personality disorder. The quarterly MDS showed the resident was cognitively intact, dependent for all ADLs, used an electric wheelchair with setup assistance, and required a mechanical lift for transfers. On 06/20/26, a progress note documented that an LPN was notified that the resident had not been seen for a while and was found on the floor in the common bathroom after another CNA had placed him on the toilet before leaving for the day. Interviews with the resident and staff described that the resident had been left on the toilet for hours while the call lights were down and there was no working call light in reach. The resident stated he had to push himself off the toilet and scoot to the door to knock for help. Staff gave conflicting accounts about whether a manual bell or a call light string was present in the bathroom, and one CNA stated she asked another aide to stay near the resident because the call system was not working correctly. The resident was later found on the bathroom floor with no call light going off, and the DON stated she could not confirm whether the call light system was working at the time of the incident.
Unclean Resident Room With Insects and Debris
Penalty
Summary
The facility failed to maintain a clean and sanitary resident room environment for one resident. Resident #360 was admitted with diagnoses including chronic kidney disease, emphysema, depression, anxiety, hypertension, epilepsy, and alcohol abuse, and her MDS indicated no cognitive impairment. During interviews, the Director of Maintenance/Housekeeping and a housekeeper stated that resident rooms were cleaned daily, but the resident reported bugs, mice, moths, and flies in her room and said staff opened her window even though there was no window screen, allowing bugs to come in. During observation of the room with the Director of Maintenance/Housekeeping present, there was no screen on the resident’s window, and the director confirmed there should have been one. The room contained several dead bugs on the windowsill, insects with wings on the wall near the window, insects behind the bed under the overhead light, moth-like bugs near the door and toilet area, several flying gnats in the bathroom, and multiple small dead bugs scattered on the floor with other unknown debris. The Director of Maintenance/Housekeeping verified these findings.
Care plans not updated for pressure ulcer care and refusal of foot hygiene
Penalty
Summary
The facility failed to revise and update care plans to reflect residents’ current needs for two residents reviewed. For Resident #367, the record showed an admission with diagnoses including vascular dementia, mild protein calorie malnutrition, type 2 diabetes mellitus, hypertension, and cerebral infarction. The quarterly MDS indicated mild cognitive impairment, ADL assistance needs, and a stage 2 pressure ulcer to the coccyx. However, wound provider notes showed the coccyx pressure ulcer had progressed to stage 3 with an onset date of 05/21/26, and the care plan last revised on 02/11/26 still only addressed potential for pressure ulcer development. The care plan was not updated to include the actual pressure ulcer, its onset, or interventions for care and treatment, including enhanced barrier precautions, until during the survey. MDS Nurse #213 verified the care plan had not been revised to reflect the wound or its treatment needs. For Resident #419, the record showed diagnoses including schizoaffective disorder, bipolar disorder, type 2 diabetes mellitus, COPD, hypertension, and obesity. The five-day MDS indicated no cognitive impairment but documented mood symptoms, ADL assistance needs, and bowel and bladder incontinence. Interviews with the Administrator, DON, RNM #242, and CNA #126 described a long history of refusing care, hygiene products, and removing shoes for bathing, with the resident preferring bed baths, keeping shoes on, and often staying in an electric wheelchair. Photographs and a video submitted by the resident’s guardian showed significant swelling and redness of both lower legs and feet, darkened areas on the feet, thickened toenails, blackened material under the nailbeds, and a live white maggot crawling on the side of the bag containing the resident’s shoes. MDS Nurse #213 verified the care plan did not reflect the resident’s refusal to remove his shoes for foot care or include staff interventions to ensure foot care was provided.
Incorrect Wound Documentation and Treatment Site
Penalty
Summary
The facility failed to accurately document a wound assessment and wound treatment orders for one resident. The resident had diagnoses including anemia, GERD, hypertension, osteoporosis, chronic kidney disease, and cognitive communication deficit. A progress note documented a wound described as two small, conjoined circles on the left buttock, while a later wound provider note identified a stage two pressure ulcer on the right buttocks. The physician orders and TAR also reflected treatment for the right buttocks, including bordered foam initially and then cleansing with normal saline, applying wound gel, and covering with a dry dressing. During observation of wound care, an LPN verified the order was for the right buttocks but performed the treatment on the resident's left buttocks instead, because the wound was observed on the left buttocks and there was no evidence of a wound on the right buttocks. The LPN confirmed that the wound provider progress note, physician order, and treatment were written incorrectly with the resident's wound documented as being on the right buttocks when it was actually on the left buttocks.
Failure to Follow EBP During Wound Care
Penalty
Summary
The facility failed to follow enhanced barrier precautions (EBP) during wound care for two residents. Resident #367 had diagnoses including vascular dementia, mild protein calorie malnutrition, major depressive disorder, type 2 diabetes mellitus, hypertension, and cerebral infarction, and had a stage three coccyx wound with an onset date of 05/21/26. During wound care observation, an EBP sign at the doorway indicated staff must wear gloves and a gown for high-contact resident care activities, including any skin opening requiring a dressing. The LPN performed hand hygiene, put on clean gloves, but did not put on a gown while providing wound care to the resident's open coccyx wound. The LPN confirmed not wearing a gown and stated a gown was not needed because there was no infection to the wound. Resident #402 had diagnoses including mild protein calorie malnutrition, peripheral vascular disease, lymphedema, hypertension, paranoid schizophrenia, and dementia, and had a stage three left buttocks wound with an onset date of 04/09/26. The resident's care plan and physician orders included EBP related to wounds, and the July 2026 treatment record showed EBP was signed off twice daily by licensed nursing staff. During wound care observation, the same EBP sign at the doorway indicated gloves and gown were required for high-contact care, but the LPN performed hand hygiene, put on clean gloves, did not put on a gown, and completed wound care on the open left buttocks wound. When the posted EBP sign was referenced, the LPN stated she would have to ask about it. The facility policy stated EBP should be used during high-contact resident care that included wound care for any skin opening requiring a dressing.
Failure to Administer Medications as Ordered at Admission
Penalty
Summary
The facility failed to administer medications as ordered for a resident admitted with multiple diagnoses, including dysphagia, dysarthria, end stage renal disease, diabetes, and hypothyroidism. Medical record review showed that upon admission, the resident had physician orders for levothyroxine 175 mcg daily for hypothyroidism and aspirin 81 mg daily for stroke prevention. However, these medications were not properly entered into the resident's orders during the admission intake process, resulting in the resident not receiving aspirin until several days after admission and levothyroxine until several months later. The Director of Nursing confirmed that the medications were not administered as ordered due to this oversight. Facility policy requires medications to be administered according to physician orders and within required timeframes.
Improper Food Storage and Dating in Kitchen
Penalty
Summary
The facility failed to properly date and store food in the kitchen, which had the potential to affect 109 of 113 residents who consumed food from the kitchen. During observations, several items in the main kitchen walk-in refrigerator were found to be improperly stored. These included an opened, undated plastic bag of whipped cream, a plastic container of cooked sausage patties dated over a month prior, undated and uncovered cups of pudding, and a container of oatmeal with a preparation date over a month old. Additionally, there were two gallons of milk past their best-by date, an opened bag of shredded cheese without a date, a metal pan of cooked noodles with no date, a plastic bag of prepared salad without a date, and three stale peanut butter and jelly sandwiches without preparation or discard dates. The Dietary Manager confirmed the issues with the dates, non-dates, and uncovered items, acknowledging that they needed to be discarded or covered. The facility's Food Receiving and Storage policy, dated December 2008, requires all food stored in the refrigerator or freezer to be covered, labeled, and dated, with refrigerated food stored to allow adequate air circulation. The policy also mandates that food items kept on nursing units be maintained below 40 degrees Fahrenheit and labeled with a use-by date. This deficiency was investigated under Complaint Number OH00163214.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to monitor and address significant weight loss in a resident, identified as Resident #121, who was admitted with multiple complex medical conditions including anemia, fractures, diabetes, and end-stage renal disease. The resident experienced a 9.5% weight loss within a month, dropping from 261.8 pounds to 236.9 pounds. Despite this significant weight change, there were no additional weights taken to verify the loss before the resident's discharge, and the weight loss was not addressed in the resident's progress or nutritional notes. The facility's policy required that any weight change of 5% or more be retaken the next day for confirmation, and if verified, the dietitian and physician should be notified. However, the Director of Nursing confirmed that the significant weight loss was neither identified nor addressed, and the necessary notifications were not made. The facility's failure to adhere to its Weight Assessment and Intervention policy resulted in this deficiency, as documented under Complaint Number OH00163214.
Failure to Timely Report and Investigate Resident Incident
Penalty
Summary
The facility failed to timely report and investigate an incident involving a resident, which resulted in a deficiency. Resident #112, who has a complex medical history including cerebral infarction, end-stage renal disease, and morbid obesity, experienced an incident during occupational therapy. The resident dropped a two-pound dumbbell on her left foot/ankle, but the therapist did not report the incident to the nursing staff or document it until a week later. The therapist also failed to conduct a full assessment of the resident's ankle at the time of the incident. The resident later complained of significant pain, leading to an x-ray that revealed a nondisplaced fracture of the distal tibia. However, an orthopedic appointment later determined it was a soft tissue injury. The facility's policy requires notification of the resident's physician and family within 24 hours of an incident, but this was not adhered to in this case. The lack of immediate reporting and assessment of the incident led to a delay in addressing the resident's injury, which was a violation of the facility's policy.
Inadequate Mouth Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate mouth care for two residents who were dependent on staff for oral hygiene. Resident #22, who had a history of stroke with left-sided weakness, paraplegia, and respiratory failure, was observed with dry and cracked lips, and skin hanging from his lips. His care plan indicated that he required assistance with mouth care every shift due to self-care performance deficits related to paraplegia. However, during an observation, it was confirmed by the Assistant Director of Nursing (ADON) that Resident #22 had not received the necessary mouth care. Similarly, Resident #88, diagnosed with quadriplegia, traumatic brain injury, and muscle weakness, was also dependent on staff for mouth care. The resident was observed with a dry mouth, cracked lips, and a significant amount of plaque buildup on his teeth. The ADON confirmed that Resident #88 required daily mouth care, which was not being provided as per the care plan. Both residents were not interviewable, and the facility's policy on Activities of Daily Living, which includes oral hygiene, was not adhered to, leading to this deficiency.
Failure in Timely Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide timely incontinence care and adequate urinary catheter care for a resident with bladder dysfunction and a history of stroke with left-sided weakness. The resident, who had impaired cognition, was incontinent of bowel and had an indwelling urinary catheter. Observations revealed that the resident's mattress pad was saturated with urine and stool, which had dried in some areas and soaked through to the mattress. Additionally, the urinary catheter had dried crusted debris around the insertion site and a thick white discharge with a foul odor was noted. Interviews with the State tested Nursing Assistants (STNAs) involved in the resident's care indicated a lack of awareness regarding the last time the resident received incontinence or catheter care. The facility's policy required catheter care to be performed every shift and as needed, but this was not adhered to. The Assistant Director of Nursing (ADON) and an STNA were also unaware of when the resident last received incontinence care, highlighting a failure in the facility's adherence to its own policies for providing appropriate care for residents unable to carry out activities of daily living independently.
Failure to Provide Appropriate Care for PEG Tube
Penalty
Summary
The facility failed to provide appropriate care for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube, which is used for nutrition and hydration. The resident, who had diagnoses including dysphasia, inhalation of food, and stroke with left-sided weakness, was observed with a PEG tube site that had dark colored crusted debris and reddened surrounding skin. The care plan for the resident required tube feedings and included interventions such as checking the feeding tube for placement and monitoring for infection at the tube site. During observations, it was noted that the State tested Nursing Assistant (STNA) did not provide care for PEG tubes, as it was the responsibility of the nurses. The Licensed Practical Nurse (LPN) confirmed the presence of crusted debris and admitted to not having provided care for the PEG tube on the observed date. Further observation with the Assistant Director of Nursing (ADON) revealed a large amount of dried crusted debris around the insertion site, which was cleaned with normal saline. The ADON stated that PEG tube sites were to be cleaned daily and as needed, indicating a lapse in the required care routine.
Failure to Supervise Smoking Residents and Secure Smoking Materials
Penalty
Summary
The facility failed to ensure a resident who required supervision with smoking was provided supervision, assistive devices to safely smoke, and smoke in a designated safe area. Resident #31, who had cognitive and physical impairments, was observed smoking unsupervised in the dining room without a cigarette holder, resulting in two blisters identified as cigarette burns on her right hand. The facility's policy required that Resident #31 be supervised while smoking and use a smoking apron and cigarette holder, but these measures were not consistently enforced. Additionally, the facility did not document the blisters or scars on Resident #31's fingers in her medical records, despite the Wound Care Nurse having observed them on multiple occasions. The facility also failed to secure smoking materials, such as lighters, and ensure residents were not smoking inside the facility. Resident #71, who was cognitively intact and an independent smoker, was observed smoking a lit cigarette in the dining room without staff supervision. The facility did not have a care plan in place for Resident #71's smoking habits, and the Director of Nursing confirmed that Resident #71 did not have a smoking care plan. Furthermore, Resident #76, who was also cognitively intact and an independent smoker, was observed with cigarettes and a lighter in his possession and admitted to lighting cigarettes for other residents. The facility did not complete a smoking assessment or care plan for Resident #76, and staff were unaware of his smoking habits. The facility's policy required smoking assessments and care plans for all residents who smoked, but these were not consistently implemented, leading to unsafe smoking practices within the facility.
Insufficient Dietary Staffing
Penalty
Summary
The facility failed to provide sufficient staff to meet the dietary needs of the residents, as observed during a breakfast tray line. On the specified date, breakfast was served in Styrofoam containers and cups due to a lack of staff, with only one Dietary Cook present. Non-dietary staff, including the HR Manager, Maintenance Director, Central Supply, Speech Therapist, and Director of Activities, were observed assisting on the tray line. The Dietary Cook was unable to conduct a test tray due to time constraints and revealed that the Dietary Manager was working from home. The lunch meal was also served in Styrofoam containers, and the same non-dietary staff assisted in the kitchen. The Dietary Cook confirmed that the department had no backup staff when people called off and required three to four Dietary Aids per shift, but this staffing level was not met. Review of the dietary staffing schedule confirmed that there were no days in April 2024 when the first shift had four Dietary Aids. Specific dates showed shifts with only one or two Dietary Aids, indicating a consistent understaffing issue. The HR Manager confirmed the required staffing levels and the deficiencies in meeting them. This deficiency was investigated under Complaint Number OH00152244 and had the potential to affect all residents except those who were NPO.
Facility Fails to Ensure Palatable and Visually Pleasurable Food
Penalty
Summary
The facility failed to ensure that food served to residents was visually pleasurable and palatable. Observations and interviews revealed that multiple residents, including Resident #33, were dissatisfied with the quality and taste of their meals. Resident #33 described the food as horrible and unappetizing, and other residents echoed similar sentiments, stating that the food was not edible, did not taste good, and was often served in Styrofoam containers. The use of Styrofoam was attributed to staff shortages, as confirmed by Dietary Cook #294. Additionally, the quiche served for breakfast was found to be burnt and rubbery, with no flavor of egg, only green pepper, and the toast was inadequately cooked on one side. The cooked rice cereal was also described as flavorless and mushy. These observations were confirmed by Dietary Tech #370 during a test tray evaluation. Further investigation revealed that the facility had not used regular eggs in three years and that the quiche was burnt due to the lack of a steamer. The toaster was also malfunctioning, toasting only one side of the bread. The Director of Nursing (DON) acknowledged that complaints about the food were common but dismissed them as matters of preference. The deficiency was investigated under Complaint Number OH00152313 and had the potential to affect all residents except those who were NPO (nothing by mouth).
Failure to Safely Store and Date Food Items
Penalty
Summary
The facility failed to safely store food and maintain a clean and sanitary kitchen, which had the potential to affect all residents except those who were NPO. During an interview, a dietary cook revealed she did not have time to observe the refrigerators with the surveyor. Upon inspection of the walk-in refrigerator with the HR Manager, it was found that multiple food items, including potato salad, macaroni, hamburger, salads, puddings, and salad dressings, were undated. Additionally, there were large spills and food particles on the floor. The HR Manager verified these observations. In another refrigerator, the dietary cook was actively dating food items as the surveyor approached, admitting that the staff had failed to do so the previous night. Items such as cheese sandwiches, stacks of cheese, liquid eggs, and a portion of pizza were found undated. The dietary cook could not recall which items she had just dated among the multiple food items in facility containers covered in saran wrap. The facility's policy on food receiving and storage, revised in December 2008, mandates that all foods stored in the refrigerator or freezer be covered, labeled, and dated with a use-by date. The observed non-compliance with this policy represents a deficiency and was investigated under Complaint Number OH00152313, continuing from a previous survey conducted in March of the same year.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Randall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenue Care And Rehabilitation Center, The | 0.6 mi | ★★★★★ | 6 | 0 |
| Phoenix Of Maple Heights | 1.1 mi | ★★★★★ | 0 | 0 |
| Harvard Gardens Rehabilitation & Care Center | 1.1 mi | ★★★★★ | 37 | 0 |
| Shaker Gardens Nursing And Rehabilitation Center | 1.9 mi | ★★★★★ | 2 | 1 |
| Beachwood Pointe Care Center | 2.4 mi | ★★★★★ | 4 | 0 |
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