Inspection Reports for Doctors Subacute Healthcare, Llc
59 Birch Street, Paterson, NJ, 07522
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 5, 2024, identified deficiencies related to medication administration errors, incomplete care planning for side rail and helmet use, and documentation issues. Earlier inspections showed a mixed pattern of deficiencies, including staffing shortages, infection control lapses, and care planning concerns. Inspectors cited medication management and care planning as recurring themes, with issues such as failure to assess medication self-administration properly and incomplete documentation. Complaint investigations were generally unsubstantiated, and no fines or enforcement actions were listed in the available reports. The facility’s inspection history shows ongoing challenges with medication and care planning, with no clear trend of improvement or worsening over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
49 residents
Based on a December 2021 inspection.
Occupancy over time
Inspection Report
Routine
Deficiencies: 7
Date: Apr 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident safety, care planning, and documentation at Doctors Subacute Healthcare, LLC.
Findings
The facility failed to ensure proper assessment and care planning for medication self-administration, medication administration errors including giving one resident another's medication, failure to report suspected abuse timely, incomplete care plans for side rail use and helmet safety, lack of quarterly reassessment of side rails, and inaccurate documentation of medication refusals and medication wastage.
Deficiencies (7)
Failed to ensure one resident was assessed for self-administration of medications, had a care plan developed, and a physician's order obtained.
One resident was given another resident's medication (amlodipine), and the borrowing of medication was not reported as a concern.
Failed to timely report suspected abuse related to medication misappropriation to the State Agency within two hours.
Failed to develop a comprehensive care plan addressing the use of side rails for one resident.
Failed to review and revise care plans to reflect correct code status and helmet use including resident refusal.
Failed to assess residents' side rails quarterly, try alternatives prior to installing side rails, and obtain physician orders for side rails for three residents.
Failed to accurately document resident helmet use and refusals, and failed to document medication disposal leading to unaccounted pills.
Report Facts
Medication bottles observed: 25
Pills missing: 5
Fall risk score: 11
Fall risk score: 5
Fall risk score: 8
Fall risk score: 13
BIMS score: 7
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in medication error finding for giving wrong resident's medication |
| Director of Nursing | Director of Nursing | Provided statements regarding medication administration and side rail assessments |
| Administrator | Administrator | Provided statements regarding reporting of medication errors and abuse |
| LPN3 | Licensed Practical Nurse | Verified incorrect code status in care plan |
| RN2 | Registered Nurse | Verified helmet refusal and care plan inaccuracies |
| RN1 | Registered Nurse | Commented on medication blister card discrepancies |
Inspection Report
Original Licensing
Deficiencies: 0
Date: 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
Date: 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)
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
Annual Inspection
Deficiencies: 3
Date: Dec 9, 2021
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with healthcare facility regulations, including care planning, respiratory care, infection control, and catheter care.
Findings
The facility was found deficient in developing comprehensive care plans for residents with indwelling urinary catheters and oxygen needs, failed to provide proper accountability and documentation for oxygen administration, and did not fully implement infection prevention and control protocols, including improper use of PPE by staff and failure to cap urinary catheter tubing.
Deficiencies (3)
Failed to develop a comprehensive care plan to address the indwelling urinary catheter needs for Resident #11.
Failed to provide accountability and documentation for oxygen administered to Resident #28 and lacked a comprehensive care plan for oxygen needs.
Failed to implement infection control protocols properly, including improper PPE use by staff and failure to follow transmission-based precautions for Resident #17 and Resident #11.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager | Licensed Practical Nurse Unit Manager | Interviewed regarding care plans for Resident #11 and catheter care |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed regarding oxygen administration for Resident #28 |
| Registered Nurse, Unit Manager | Registered Nurse, Unit Manager | Interviewed regarding oxygen care plan and documentation for Resident #28 |
| Director of Nursing | Director of Nursing | Discussed concerns about catheter care, oxygen documentation, and infection control |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Discussed infection control concerns and respiratory protection program |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed about urinary drainage bag storage and catheter tubing |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Mar 15, 2021
Visit Reason
The inspection was conducted in response to complaint #NJ 143619 to assess compliance with regulatory requirements.
Complaint Details
Complaint # NJ 143619 was investigated and the facility was found to be in substantial compliance.
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.
Report Facts
Sample Size: 3
Inspection Report
Abbreviated Survey
Census: 42
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (1)
Failure to disinfect and sanitize the equipment used in the COVID-19 screening process in accordance with CDC guidelines.
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 |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 3, 2020
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights, care plans, wound care, medication management, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to establish an anonymous grievance system, inadequate individualized care plans and accountability for resident showering, improper pressure ulcer care and offloading, and inaccurate accountability and reconciliation of controlled drugs.
Deficiencies (4)
Failed to establish a system for residents to file grievances anonymously.
Failed to ensure individualized care plans addressed resident's showering needs and preferences and lacked accurate accountability for showering.
Failed to apply pressure ulcer treatment in accordance with manufacturer specifications and ensure accountability for offloading of heels for diabetic pressure ulcers.
Failed to maintain accurate accountability and reconciliation for a controlled drug (Methadone).
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Methadone bottles discrepancy: 1
BIMS score: 13
BIMS score: 12
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Social Worker | LSW | Interviewed regarding grievance process and lack of anonymous grievance system |
| Licensed Nursing Home Administrator | LNHA | Acknowledged no anonymous grievance system and inability to provide documented evidence of such system |
| Director of Nursing | DON | Interviewed regarding showering care plan deficiencies and wound care treatment issues |
| Certified Nursing Aide | CNA | Interviewed regarding shower schedules and resident care |
| Licensed Practical Nurse/Unit Manager | LPN/UM | Interviewed regarding shower schedules, wound care, and medication accountability |
| Clinical/Registered Nurse | C/RN | Observed performing wound care and interviewed about treatment procedures |
| Consultant Pharmacist | CP | Interviewed regarding controlled drug inventory and reconciliation procedures |
Notice
Deficiencies: 0
Date: 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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