Inspection Reports for Doctors Subacute Healthcare, Llc
59 Birch Street, NJ, 07522
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Inspection Report
Original Licensing
Deficiencies: 0
Mar 25, 2022
Visit Reason
Inspection for licensure of new and/or renovated long term care facilities, specifically the expansion of the existing rehabilitation gym using the existing multi-purpose room.
Findings
No deficiencies were noted during the inspection of the expansion projects involving separation and new wall construction of the multi-purpose room and expansion of the rehabilitation gym. The areas may not be occupied until formal notification by the Certificate of Need and Licensing Division is received.
Inspection Report
Plan of Correction
Census: 49
Deficiencies: 2
Dec 9, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, focusing on staffing ratios and infection control requirements.
Findings
The facility failed to meet minimum staffing ratios for Certified Nurse Aides (CNAs) on 10 of 14 day shifts reviewed, potentially affecting all residents. Additionally, the facility failed to ensure one of five newly hired employees received the required two-step Mantoux tuberculin skin test upon employment.
Deficiencies (2)
| Description |
|---|
| Failure to ensure staffing ratios were met for 10 of 14 day shifts reviewed, with CNA staffing below required minimums. |
| Failure to ensure 1 of 5 newly hired employees received the required two-step Mantoux tuberculin skin test upon employment. |
Report Facts
Residents present: 49
Day shifts with deficient CNA staffing: 10
Required CNAs per day shift: 7
Actual CNAs present on deficient days: 5
Newly hired employees reviewed: 5
Employees missing two-step Mantoux test: 1
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Mar 15, 2021
Visit Reason
The inspection was conducted in response to complaint #NJ 143619 to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint # NJ 143619 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
Inspection Report
Abbreviated Survey
Census: 42
Deficiencies: 0
Feb 23, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 1
Jan 22, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations, specifically failing to disinfect and sanitize equipment used in the COVID-19 screening process according to CDC guidelines, including lack of disinfecting wipes and failure to sanitize the kiosk and pen after each use.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to disinfect and sanitize the equipment used in the COVID-19 screening process in accordance with CDC guidelines. | SS=D |
Report Facts
Census: 45
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Acknowledged lack of disinfecting wipes and failure to sanitize kiosk and pen | |
| Director of Nursing (DON) | Provided information on receptionist education and facility policies |
Notice
Deficiencies: 0
Apr 15, 2011
Visit Reason
This document serves as a Notice of Privacy Practices to inform individuals about how their medical information may be used and disclosed by NJDHSS and to explain their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, and NJDHSS's legal duties and policies for protecting privacy.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice and privacy policies. |
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