Deficiency Records for Suburban Healthcare and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Suburban Healthcare and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-17 | 2024-02-02 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-17 | 2024-02-02 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-17 | 2024-02-02 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-01-17 | 2024-02-02 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-17 | 2024-02-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-17 | 2024-02-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-17 | 2024-02-02 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2024-01-17 | 2024-02-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-05 | 2023-09-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-14 | 2023-07-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-02 | 2023-05-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-02 | 2023-05-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-11 | 2023-05-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-11 | 2023-05-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-11 | 2023-05-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-11 | 2023-05-17 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-11 | 2023-05-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-11 | 2023-05-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-11 | 2023-05-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-06 | 2023-03-09 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-02-04 | 2022-03-25 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-02-04 | 2022-03-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-04 | 2022-03-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-02-04 | 2022-03-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-04 | 2022-03-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-04 | 2022-03-25 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-02-04 | 2022-03-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-04 | 2022-03-25 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-02-04 | 2022-03-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-04 | 2022-03-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-02-04 | 2022-03-25 | N |
| Keep all essential equipment working safely. | Health | 2022-02-04 | 2022-03-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-04 | 2022-03-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-04 | 2022-03-25 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-04 | 2022-03-25 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-02-04 | 2022-03-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-04 | 2022-03-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-04 | 2022-03-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-04 | 2022-03-25 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-02-04 | 2022-03-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-04 | 2022-03-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-04 | 2022-03-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-04 | 2022-03-25 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-02-04 | 2022-03-25 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-02-04 | 2022-03-25 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-02-04 | 2022-03-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-04 | 2022-03-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-03-25 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-17 | 2022-03-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-17 | 2022-03-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-17 | 2022-03-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-01 | 2022-03-25 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-01 | 2022-03-25 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-26 | 2022-03-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-26 | 2022-03-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-26 | 2022-03-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-26 | 2022-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-26 | 2022-03-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-26 | 2022-03-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-26 | 2022-03-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-26 | 2022-03-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-26 | 2022-03-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-26 | 2022-03-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-09-07 | 2021-09-30 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-09-07 | 2021-09-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-07 | 2021-09-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-18 | 2021-09-30 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-04-30 | 2021-05-17 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-04-08 | 2021-05-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-08 | 2021-05-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-08 | 2021-05-17 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-08 | 2021-05-17 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-04-08 | 2021-05-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-08 | 2021-05-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-03 | 2021-05-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-03 | 2021-05-17 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-03-03 | 2021-05-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-15 | 2020-02-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-01-15 | 2020-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-15 | 2020-02-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-01-15 | 2020-02-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-29 | 2019-01-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-11-29 | 2019-01-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-29 | 2019-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-29 | 2019-01-31 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-11-29 | 2019-01-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-11-29 | 2019-01-31 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-11-29 | 2019-01-31 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-11-29 | 2019-01-31 | N |
| Provide or obtain dental services for each resident. | Health | 2018-11-29 | 2019-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-29 | 2019-01-31 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-29 | 2019-01-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-29 | 2019-01-18 | N |
