A list of the most recent deficiencies for Suburban Woods Health and Reha. 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? |
|---|---|---|---|---|
| List the names and contact information of those in the facility. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Use approved construction type or materials. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-14 | 2023-11-02 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-09-05 | 2023-10-10 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-09-05 | 2023-10-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-05 | 2023-10-10 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-05 | 2023-10-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-05 | 2023-10-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-05 | 2023-10-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-05 | 2023-10-10 | 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 | 2023-09-05 | 2023-10-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-09 | 2023-05-01 | Y |
| Meet other general requirements. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-09 | 2023-01-09 | 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 | 2022-12-09 | 2023-01-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-09 | 2023-01-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-10-21 | 2022-11-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-10-21 | 2022-11-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-21 | 2022-11-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-21 | 2022-11-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-10 | 2022-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-10 | 2022-01-31 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-11-10 | 2021-12-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-10 | 2021-12-21 | 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 | 2021-11-10 | 2021-12-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-10 | 2021-12-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-10 | 2021-12-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-10 | 2021-12-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-10 | 2021-12-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-10 | 2021-12-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-21 | 2021-11-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-21 | 2021-11-23 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-10-21 | 2021-11-23 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-10-21 | 2021-11-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-21 | 2021-11-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-21 | 2021-11-23 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-10-21 | 2021-11-23 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-21 | 2021-11-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-21 | 2021-11-23 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-10-21 | 2021-11-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-10-21 | 2021-11-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-10-21 | 2021-11-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-21 | 2021-11-23 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-10-21 | 2021-11-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-21 | 2021-11-23 | N |
