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Deficiency Records for Suburban Woods Health and Reha
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.
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? |
|---|---|---|---|---|
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-06-25 | 2024-09-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-25 | 2024-09-13 | 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 | 2024-06-25 | 2024-09-13 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2024-06-25 | 2024-09-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-25 | 2024-09-13 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Meet other general requirements. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-06-25 | 2024-07-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-06-25 | 2024-07-31 | 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 | 2024-05-17 | 2024-06-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-17 | 2024-06-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-17 | 2024-06-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-17 | 2024-06-11 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-05-17 | 2024-06-11 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-05-17 | 2024-06-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-05-17 | 2024-06-11 | N |
| 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 |
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