Doctors Subacute Healthcare, LLC

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 1 (one) of the 13 residents (Resident #1) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: On 9/21/2025 10:55 AM, the surveyor observed Resident #1 in bed, awake, and able to answer the surveyor's inquiry. The surveyor observed that the call device was tied to the resident's arm rail and was dangling towards the floor. The surveyor asked the resident if the resident was able to use the call bell, and the resident stated, I am not sure where it is; I just yell out to the staff for help. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 3 of 13 residents (Resident #3, 5, and #51) during the review of resident assessment. This deficient practice was evidenced by the following: The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. [...]

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines, for 1 (one) of 13 residents (Resident #3), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 9/21/2025 at 10:11 AM, the surveyor observed Resident #3 in bed watching television, alert and oriented x3, able to answer questions appropriately. On 9/22/2025 at 9:37 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #3, which revealed the following: [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to ensure that the residents' Primary Physician (PP) or an alternating advanced practice nurse (APN) signed the monthly Physician Orders (PO). The deficient practice was observed for 3 of 13 residents (Resident #3, 5, and #47) reviewed and occurred over the previous 6 months. This deficient practice was evidenced by the following: 1. A review of the electronic Medical Record (eMR) for Resident #3 revealed that PP #1 or an alternating APN has not electronically signed the monthly POs of April, May, July, and September 2025. 2. A review of the eMR for Resident #5 revealed that the PP #2 has not electronically signed the monthly PO from April to September 2025. 3. [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure the consistent hospice services were provided, in accordance with professional standards and principles to meet the resident's needs (Resident #6). This deficient practice was identified for one (1) of one (1) resident reviewed for hospice and end of life care. This deficient practice was evidenced by the following:On 9/21/25 at 10:19 AM, during the initial tour, the surveyor observed Resident #6 seated at the edge of the bed, eating from a plastic container and had a bruise on their upper lip. The surveyor reviewed the medical record for Resident #6. According to the admission Record (AR; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure Resident #28 was offered pneumococcal vaccination according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations. This deficient practice was identified for one (1) of five (5) residents reviewed for immunization status. The deficient practice was evidenced by the following:Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 2/13/23, included the following. [...]

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure that one resident (Resident (R) 35) of one resident observed with medications at the bedside was assessed for self-administration of medications, a care plan developed and a physician's order for self-administering medication was obtained.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to ensure that one resident (Resident (R) 6) from four residents observed during medication administration were given their medication. Specifically, R6 did not have his amlodipine medication and was given another resident's (R17) amlodipine medication.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure an incident of misappropriation of resident property for one of one resident (Resident (R) 17) was reported to the State Agency (SA) within two hours of receiving report that a nurse gave R17's medication to another resident (R6) during medication administration.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure that one (Resident (R) 22) of seven residents reviewed for side rails had a comprehensive care plan developed that addressed the use of side rails.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure one of 12 residents (R)8) care plans were reviewed and revised to reflect the correct code status after it was changed and for one of 12 residents (R47) care plans reviewed, failed to ensure the physician's ordered helmet for safety and the resident's refusal to wear the helmet was included in the care plan.

Inspectors wroteNJAC 8:39-27.1(a) Based on observations, record reviews, interviews and policy review, the facility failed to residents' side rails were assessed quarterly according to the facility's policy, failure to ensure alternatives were tried prior to installing a side rail; and failed to ensure bed rails were ordered by the physician prior to use for three (Resident (R) 41, R4, and R22) of 10 residents reviewed for side rails.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure one of one Resident (R)47) use of a helmet was accurately documented in the treatment records and electronic medical record (EMR). In addition, nursing staff failed to document for one of one resident (R23) when a medication was disposed of to ensure that all dosages for the medication was accurately accounted for in the EMR.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan to address the indwelling urinary catheter need for 1 of 1 resident (Resident #11) reviewed for catheter care and evidence by the following: On 12/5/21 at 10:30 AM, the surveyor observed Resident #11 in bed with eyes closed. The resident had an indwelling urinary catheter drainage bag hanging at the right side of the bed inside a privacy bag. The surveyor reviewed the Electronic Medical Records for Resident #11 that revealed the following: According to the readmission Progress Notes dated 10/20/21, Resident #11 was readmitted with diagnoses that included Acute Renal Injury and Acute Urinary Retention. The nurses documented that the resident now has an indwelling urinary catheter. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide accountability for the oxygen administered to a resident. This deficient practice was identified for Resident #28 1 of reviewed for oxygen services and was evidenced by the following: On 12/05/21 at 10:23 AM, the surveyor observed Resident # 28 in the bed with oxygen via nasal cannula (NC) at 3 liters per minute (LPM) and the oxygen tube was dated 11/29/21. The resident stated that he/she received oxygen when he/she had trouble breathing. On 12/06/21 at 9:16 AM, the surveyor observed Resident # 28 in bed, with oxygen via NC at 3 LPM. The surveyor reviewed Resident #28's electronic medical record (EMR) that revealed the following: According to the admission Record, Resident #28 was admitted with diagnoses which included Iron Deficiency Anemia. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to implement infection control protocols in a manner that would decrease the possibility of the spread of infection. This was found with 1 of 1 residents on transmission based precautions, Resident # 17, and 1 of 1 residents with an indwelling urinary catheter, Resident # 11. The deficient practice was evidenced by the following: 1. On 12/5/21 at 9:15 AM, the weekend nursing supervisor informed the survey team that Resident #17 was on transmission based precautions for suspicion of Covid-19 because the resident was unvaccinated for Covid-19 and was re-admitted to the facility on [DATE] from the hospital. [...]