Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Doctors Subacute Healthcare, Llc during CMS and state inspections, most recent first.
The facility failed to assess a resident for self-administration of medications, develop a care plan, and obtain a physician's order. The resident had 25 medication bottles on her overbed table, and an LPN left her prescribed medication without observing her take it. The DON confirmed the lack of assessment, physician order, and care plan for self-administering medications.
A resident did not receive their prescribed amlodipine medication and was instead given another resident's medication by an LPN. The facility's DON and Administrator were unaware of the missing medication and did not consider the incident reportable, referring to it as borrowing rather than misappropriation.
The facility failed to report an incident of misappropriation of resident medication to the State Agency within the required two-hour timeframe. An LPN gave a resident's medication to another resident on multiple occasions, and the incident was not reported immediately as required by the facility's policy.
The facility failed to develop a comprehensive care plan for a resident regarding the use of side rails. The resident, who has Parkinson's disease, blindness in one eye, and difficulty walking, was observed with side rails up on multiple occasions. Despite being cognitively intact, there was no care plan addressing the side rails, as confirmed by the DON.
The facility failed to update a resident's care plan to reflect the correct DNR/DNI code status and did not include a physician-ordered helmet or the resident's refusal to wear it in another resident's care plan. These deficiencies were confirmed through observations and staff interviews.
The facility failed to ensure that side rails were assessed quarterly, alternatives were tried before installation, and physician orders were obtained for three residents. Observations and interviews revealed that side rails were in use without proper documentation and reassessment, contrary to the facility's policy.
The facility failed to document a resident's refusal to wear a helmet and to account for all dosages of a medication for another resident. The helmet use was not accurately recorded in the EMR, and five pills were unaccounted for due to a lack of documentation for wasted medications.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident (R35) was assessed for self-administration of medications, a care plan was developed, and a physician's order for self-administering medication was obtained. During an observation, it was noted that R35 had a box containing 25 medication bottles on her overbed table. These included various supplements and medications such as olive leaf extract, probiotics, calcium citrate, and vitamin D-3. Additionally, a Licensed Practical Nurse (LPN) left a cup containing R35's prescribed nifedipine medication on the overbed table without observing her take it. The LPN stated that R35 would not take medication if someone watched her and confirmed that there was no order for these medications or supplements. The Director of Nursing (DON) confirmed that R35 did not have an assessment, physician order, nor a care plan for self-administering medications. Review of R35's records revealed that she was admitted to the facility with a diagnosis of hypertension and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she was cognitively intact. However, there was no evidence in the electronic medical record (EMR) that R35 was assessed for self-administering medication and/or supplements. The facility's policy on self-administering medications requires an interdisciplinary team (IDT) assessment, a physician's order, and documentation in the resident's care plan, none of which were completed for R35. The DON indicated that she expected no medications to be left at the bedside, confirming the facility's failure to adhere to its own policy and regulatory requirements.
Medication Misappropriation Incident
Penalty
Summary
The facility failed to ensure that a resident received their prescribed medication, leading to the administration of another resident's medication. During a medication administration observation, an LPN discovered that a resident's amlodipine medication was not available in the medication cart. Instead of following proper protocol, the LPN administered another resident's amlodipine medication to the resident in need. This action was confirmed through interviews and record reviews, which showed that the medication was borrowed on multiple occasions without proper documentation or consent. The facility's policy clearly states that each resident has the right to be free from misappropriation of property, which includes the wrongful use of another resident's medication. However, the LPN and the DON did not consider this incident as a reportable concern, referring to it as borrowing rather than misappropriation. Further investigation revealed discrepancies in the medication records and the facility's handling of the situation. The DON and the Administrator were unaware of the missing medication and did not report any investigation into the missing pills. The pharmacy confirmed that the medication was sent to the facility, but the medication was not found in the medication cart. Additionally, the DON mentioned that there were alternative sources for the medication within the facility, but the LPN was unaware of these options. The facility's failure to properly manage and document medication administration led to the misappropriation of a resident's medication, violating the resident's rights and the facility's policies.
Failure to Timely Report Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report an incident of misappropriation of resident property to the State Agency (SA) within the required two-hour timeframe. During a medication administration observation, an LPN gave a resident's (R17) medication to another resident (R6) because R6's medication had not been received from the pharmacy. This occurred on multiple occasions, as documented in the Medication Administration Record (MAR) for both residents. The LPN admitted to borrowing R17's medication for R6 on at least two days. Interviews with the Director of Nursing (DON) and the Administrator revealed that they did not consider the incident reportable. The Administrator indicated that he was waiting for feedback from the survey team before reporting the incident to the SA. The facility's policy requires immediate reporting of such incidents, but the report was only sent to the SA the following day. This delay in reporting is a violation of the facility's policy and state regulations.
Failure to Develop Comprehensive Care Plan for Side Rails
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed for a resident (R22) regarding the use of side rails. R22, who was readmitted to the facility with Parkinson's disease, blindness in the left eye, and difficulty walking, was observed on multiple occasions with bilateral half side rails in the up position. Despite R22's cognitive intactness, as indicated by a BIMS score of 13 out of 15, there was no evidence of a side rail care plan or side rails as an intervention in R22's care plans. The Director of Nursing confirmed the absence of a side rail care plan for R22.
Failure to Update Care Plans for Code Status and Safety Equipment
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised to reflect the correct code status after it was changed. Specifically, for one resident with severe cognitive impairment, the care plan incorrectly indicated a full code status despite the resident's POLST form and physician's orders indicating a DNR/DNI status. This discrepancy was verified by both an LPN and an RN during interviews, and the Administrator and DON confirmed that the care plan had not been updated to reflect the correct advanced directive. Additionally, the facility failed to include a physician-ordered helmet for safety and the resident's refusal to wear the helmet in another resident's care plan. This resident, who was at high risk for falls and had moderate cognitive impairment, was observed multiple times without the helmet. Interviews with an RN and the MDS Coordinator confirmed that the care plan did not document the helmet order or the resident's refusal to wear it. The facility's policy stated that care plans should be reviewed and revised as the resident's condition changes, but this was not followed in these cases.
Failure to Assess and Reassess Side Rails Quarterly
Penalty
Summary
The facility failed to ensure that residents' side rails were assessed quarterly according to the facility's policy, did not try alternatives before installing side rails, and did not obtain physician orders for the use of side rails for three residents. Resident 41 was observed with half side rails in the up position, but the only side rail assessment found was from the admission evaluation dated over a year ago. There was no physician order for the use of side rails, and the quarterly assessments were not documented as required by the facility's policy. The Director of Nursing (DON) confirmed that side rails should be evaluated quarterly, but this was not done for Resident 41. Resident 4 was observed with bilateral upper half side rails in the up position and was unsure why they were there. The resident's quarterly Minimum Data Set (MDS) assessment indicated moderate cognitive impairment, and although there was an informed consent form dated 2020, there was no documentation of quarterly reassessments for the side rails. The DON confirmed that the side rail assessments were not reassessed quarterly as per the facility policy. Resident 22 was observed with bilateral half side rails in the up position and was unsure why they were there. The resident's quarterly MDS assessment indicated cognitive intactness, but there was no evidence of a physician order for side rails or quarterly side rail assessments. The DON confirmed that the side rail assessments were not being reassessed quarterly and that no alternatives were listed before the side rails were placed. The facility's policy requires side rails to be monitored and re-evaluated quarterly, but this was not followed for Resident 22.
Inaccurate Documentation of Helmet Use and Medication Disposal
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's use of a helmet and the disposal of medication. Resident 47, who had a moderately impaired cognition and was at high risk for falls, had a physician's order to wear a helmet at all times while out of bed. However, the resident was observed multiple times without the helmet, and there was no documentation of the resident's refusal to wear the helmet in the electronic medical record (EMR) or the Treatment Administration Record (TAR). Staff confirmed that the documentation was not accurate, and the refusals were not recorded as required. Additionally, the facility failed to account for all dosages of a medication for Resident 23. The resident's blister card for amlodipine showed discrepancies between the number of pills punched out and the number documented in the Medication Administration Record (MAR). Five pills were unaccounted for, and there was no system in place for documenting the disposal of non-narcotic medications. Staff interviews revealed that the missing pills could not be traced, and the Director of Nursing confirmed the lack of documentation for wasted medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Preakness Healthcare Center | 1.8 mi | — | 1 | 0 |
| Barnert Subacute Rehabilitation Center, Llc | 2.1 mi | — | 0 | 0 |
| Atlas Rehabilitation Healthcare At Daughters Of Mo | 2.5 mi | — | 2 | 0 |
| Excel Care At Wayne | 2.7 mi | — | 2 | 1 |
| Complete Care At Fair Lawn Edge | 2.8 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.