Suburban Healthcare: Medications Missed for Months - OH
The resident, identified only as Resident #10 in federal inspection records, was admitted to the facility on a date the report does not specify. Her diagnoses included dysphagia, dysarthria, end-stage renal disease, diabetes, and hypothyroidism. She had impaired cognition, requiring staff help with bathing, dressing, and personal care. Her hospital discharge paperwork, present in her medical record, included a clear order for aspirin 81 milligrams once daily to reduce the risk of a subsequent stroke, and levothyroxine 175 micrograms once daily to treat her hypothyroidism.
Neither drug was added to her medication orders when she was admitted.
The aspirin went unnoticed first. According to medication administration records reviewed by inspectors, Resident #10 did not receive her aspirin until October 20, 2024. The levothyroxine took longer to catch. She did not receive her first dose of the thyroid medication until June 25, 2025. Both failures traced back to the same source: an oversight during admission intake.
The Director of Nursing confirmed both gaps during an interview with inspectors on August 15, 2025.
Aspirin at that dose is prescribed after a stroke or transient ischemic attack specifically to reduce clotting and lower the risk of a second event. The resident's discharge paperwork listed the order explicitly for that purpose. Levothyroxine replaces thyroid hormone the body cannot produce on its own; without it, patients with hypothyroidism can experience fatigue, cognitive decline, and cardiovascular strain, risks that compound in someone already managing end-stage renal disease and diabetes.
The inspection, conducted August 16, 2025, was triggered by a complaint, not a routine survey. Inspectors reviewed three residents' medication records and found the breakdown in one of them.
What the records show is not a complex clinical failure. The discharge summary was in the chart. The orders were written. The drugs were prescribed by a physician who had already treated this patient. At the moment of admission, when facility staff were responsible for translating those orders into an active medication regimen, both prescriptions were simply left out. The facility's own medication policy states that drugs must be administered in accordance with orders, including any required timeframe.
For Resident #10, a woman who could not manage her own care, who depended on staff to bathe and dress her, and whose cognition was impaired enough that she could not reliably advocate for herself, the gap between what was ordered and what was given stretched across weeks for one medication and more than eight months for the other.
The inspection report does not document what, if any, clinical harm resulted. It rates the deficiency at the level of minimal harm or potential for actual harm. It does not say whether her thyroid levels were monitored during the months she went without levothyroxine, or whether anyone tracked her stroke risk in the absence of the aspirin.
What it does say is that a 115-resident facility, responding to a formal complaint, was found to have left a cognitively impaired woman without two prescribed medications, one of them ordered to prevent a stroke, because no one checked the paperwork closely enough on the day she arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Suburban Healthcare and Rehabilitation from 2025-08-16 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
SUBURBAN HEALTHCARE AND REHABILITATION in NORTH RANDALL, OH was cited for violations during a health inspection on August 16, 2025.
The resident, identified only as Resident #10 in federal inspection records, was admitted to the facility on a date the report does not specify.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.