Suburban Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Suburban Healthcare and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 27, 2026

  Based on closed medical record review, review of hospital records, review of photo and video records, review of facility witness statements, review of facility staffing and payroll documents, policy review and interview, the facility failed to protect Resident #419's right to be free from neglect. This affected one resident (#419) of two residents reviewed for neglect. The facility census was 119.Actual Harm occurred on 07/01/26 when Resident #419 was transferred to the hospital for a scheduled procedure and hospital staff identified the resident with caked feces, a maggot infestation, and multiple superficial wounds to both feet with cellulitis of the lower extremities which required medical intervention and subsequent admission to the hospital. […]

• Actual harm, isolatedF603Jul 27, 2026

  Based on medical record review, review of email communication, fall investigation review, resident and staff interview, and facility policy review, the facility failed to ensure Resident #334 was free from an incident of involuntary seclusion. This affected one resident (#334) of two residents reviewed for quality of care and services. The facility census was 119.Actual physical and psychosocial harm occurred on 06/20/26 when Resident #334, who had quadriplegia (partial or total loss of function in all four limbs) and was dependent on staff for toileting, was left alone without supervision on a toilet in a locked common bathroom requiring a code to open without evidence of a functional call signal system. […]

• Actual harm, isolatedF689Apr 22, 2024

  Based on observations, resident interviews, staff interviews, medical record review, and policy review, 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. Actual harm occurred to one resident (#31) when Resident #31, who was observed smoking in the dining room, unsupervised and without a cigarette holder, was found to have two blisters, verified as cigarette burns on the right index finger near the nail and on the middle finger between the first and second knuckle. […]

• Actual harm, isolatedF689Mar 7, 2024

  Based on medical record review, review of a wound care report, investigative report, and staff and resident interviews, the facility failed to ensure Resident #39's environment remained free of an accident hazard when the resident's soup was served at an unsafe temperature causing an injury. This affected one resident (#39) of six residents reviewed for accidents. The facility census was 111. Actual harm occurred on 01/29/24 between approximately 5:00 P.M. and 6:00 P.M. when Resident #39 sustained first and second degree burns to her right anterior thigh after spilling soup which a State tested Nursing Assistant (STNA) had warmed up in a microwave and served to Resident #39. The burn went unreported until the next day, 01/30/24, when Resident #39 asked a nurse to assess the area. […]

• Actual harm, isolatedF790Jan 17, 2024

  Based on observation, resident and staff interviews, record review, and policy review, the facility failed to provide routine dental and oral care for a resident dependent on staff for all activities of daily living. Actual Harm occurred when Resident #65 was not provided routine dental/oral care and treatment resulting in the resident expressing pain in his mouth, the resident's gums being red and inflamed with areas of dried blood, multiple broken, cracked, split, black upper and lower teeth, and foul-smelling breath. The lack of routine dental care had the potential to lead to serious complications including but not limited to infection and/or sepsis. This affected one (#65) of five residents reviewed for dental care. […]