Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 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.
Call Device Not Within Resident's Reach: A resident with a right humerus fracture, repeated falls, muscle weakness, and moderate cognitive impairment was observed in bed with the call device tied to the arm rail and dangling toward the floor. The resident stated the call bell was not easy to find and that help was requested by yelling out to staff. Records showed the resident needed assistance with ADLs and had a care plan encouraging use of the call device, while staff stated the call device should be within easy reach.
Delayed MDS Transmission: The facility failed to transmit required MDS assessments within the federal timeframe for three residents. The MDSC/RN stated she was catching up after a prior backlog, and record review showed that an annual MDS, a quarterly MDS, and an admission MDS were all completed and transmitted late. The DON provided no additional information when the concern was reviewed.
A resident with schizophrenia had an annual MDS that coded PASRR as Level I/No, even though the record included a PASSR Level II Determination Notification and the care plan documented a positive PASSR level I & II. The SSD and MDSC both stated the resident should have been coded as Level II, and the MDS was coded incorrectly.
A facility failed to ensure that the PP or alternating APN electronically signed monthly POs for 3 residents. Record review showed multiple months without required signatures for one resident, another resident, and a third resident, despite the RN/UM stating the physician visits the facility monthly and signs orders in the eMR. The facility policy required all verbal or written orders to be signed by the prescriber monthly.
A resident with severe cognitive impairment, dementia, DM2, and PVD was receiving hospice services, but surveyors found inconsistent hospice documentation and unclear visit frequency. The resident was observed with a bruise on the upper lip, and records showed the last hospice aide visit was documented much earlier than the RN visits. The RN/UM could not explain the gap, the CHHA confirmed the last aide visit date, and the DON stated hospice visits were expected weekly with constant communication.
Missed Follow-Up Pneumococcal Vaccine Offer: A resident with COPD, HF, and CKD stage 3 received PPSV23, but the record did not show that PCV20, PCV21, or PCV15 was offered afterward per CDC/ACIP guidance. The MDS marked the pneumococcal vaccine as current, yet the eMAR lacked documentation of a subsequent offer, and the RN/IP could not confirm that the resident had been tracked for additional pneumococcal vaccination.
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.
Call Device Not Within Resident's Reach
Penalty
Summary
The facility failed to ensure that a resident's call device was readily accessible. During observation, the resident was found in bed, awake, and able to answer questions, but the call device was tied to the arm rail and dangling toward the floor. When asked about using the call bell, the resident stated, "I am not sure where it is; I just yell out to the staff for help." The resident had diagnoses that included a fracture of the upper end of the right humerus, repeated falls, muscle weakness, and cerebral infarction, and the admission MDS showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Record review showed that the resident required assistance with daily living activities and had a care plan that included encouraging use of the call device for assistance. Staff interviews indicated that the call device should be within the resident's reach and that staff make sure it is easily accessible so the resident can call for help. The facility policy titled "Call light Answering" stated that the call bell should be positioned within easy reach of the resident.
Delayed MDS Transmission
Penalty
Summary
The facility failed to complete and transmit MDS assessments in accordance with federal guidelines for 3 of 13 residents reviewed. The MDS is a federally mandated comprehensive assessment tool that must be completed and electronically transmitted to the Quality Measure System within 14 days of completion. During the review, the surveyor identified that Resident #3, Resident #5, and Resident #51 each had an MDS that was not transmitted within the required timeframe, and requested the final validation reports from CMS. The MDS Coordinator/RN stated she started in June and that the former MDSC was also behind, and she was catching up. Review of the records showed that Resident #3’s annual MDS had an ARD of 8/15/25, was signed as completed on 9/3/25, and was not transmitted until 9/6/25. Resident #5’s quarterly MDS had an ARD of 7/21/25 and was signed as completed and not transmitted until 8/11/25. Resident #51’s admission MDS had an ARD of 7/26/25 and was signed as completed and not transmitted until 8/11/25. The surveyor also met with the DON regarding the concern, and no information was provided.
Incorrect PASRR Coding on MDS
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident who was reviewed for MDS accuracy. The resident was observed in bed watching television, alert and oriented x3, and able to answer questions appropriately. Record review showed the resident was admitted with schizophrenia and had an annual MDS dated 8/15/24 that assessed cognitive status with a BIMS score of 8 out of 15, indicating moderately impaired cognition. The annual MDS also coded Section A1500, PASRR, as "0. No" for whether the resident was currently considered by the state-level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. However, the resident's record included a PASSR Level II Determination Notification showing that a Level II PASRR had been completed and that the resident had mental health treatment needs that could be met in a nursing facility. The care plan also documented that the resident had a positive PASSR level I & II completed. The SSD and MDSC both stated during interviews that the resident should have been coded as Level II and that the prior coding was wrong.
Monthly Physician Orders Not Signed
Penalty
Summary
The facility failed to ensure that the residents' Primary Physician or an alternating APN electronically signed the monthly Physician Orders for 3 of 13 residents reviewed: Resident #3, Resident #5, and Resident #47. Record review showed that Resident #3 did not have monthly POs signed for April, May, July, and September 2025, Resident #5 did not have monthly POs signed from April through September 2025, and Resident #47 did not have monthly POs signed for April, May, July, and September 2025. During an interview, the RN/Unit Manager stated that the physician comes to the facility at least once a month and documents and signs the monthly PO in the eMR, but the record review did not show the required signatures. The facility policy titled Physician Orders, reviewed 12/2024, stated that all verbal or written orders must be signed by the prescriber monthly.
Inconsistent Hospice Services and Documentation
Penalty
Summary
The facility failed to ensure consistent hospice services were provided for a resident with unspecified dementia, type 2 diabetes mellitus, acquired absence of the right toe, and peripheral vascular disease. The resident’s quarterly MDS showed a BIMS score of 4 out of 15, indicating severely impaired cognition, and documented that the resident received hospice services while in the facility. The care plan included an intervention to communicate the resident’s needs to hospice and work together to obtain comfort and care, and the active order summary included a physician order for palliative/hospice evaluation and treatment. Surveyors observed the resident seated at the edge of the bed eating from a plastic container and noted a bruise on the upper lip. Review of hospice records showed the last hospice aide visit was documented on 7/11/25, while the hospice care log reflected RN visits on 7/1/25, 8/29/25, 9/5/25, and 9/18/25, and one LPN visit on 7/23/25. During interview, the RN/UM was unsure how often the hospice aide and RN visited and could not explain why the aide record showed the last visit as 7/11/25. The CHHA confirmed that 7/11/25 was the last aide visit recorded, and the DON stated the expectation was for constant communication with hospice and weekly visits.
Missed Follow-Up Pneumococcal Vaccine Offer
Penalty
Summary
The facility failed to ensure that Resident #28 was offered pneumococcal vaccination in accordance with current CDC and ACIP recommendations. The resident’s immunization record showed receipt of PPSV23 on 12/11/23, with consent signed on 12/6/23, but the electronic medication record did not show that PCV20, PCV21, or PCV15 was offered at least one year later as recommended for adults 65 years or older who had only received PPSV23. The resident’s admission record listed diagnoses including COPD, heart failure, and chronic kidney disease stage 3, and the most recent quarterly MDS showed a BIMS score of 14 out of 15, indicating intact cognition. The quarterly MDS marked the resident’s pneumococcal vaccine status as current, yet the record review did not show documentation that the follow-up pneumococcal vaccine was offered after the PPSV23 dose. During interview, the RN/Infection Preventionist stated that residents were provided information and offered immunizations at admission, but was not aware whether this resident had been offered a subsequent pneumococcal vaccine and could not show documentation of surveillance for residents needing additional pneumococcal vaccination. The DON was informed that the resident’s assessment reflected the vaccine was current even though the last documented pneumococcal immunization in the facility was PPSV23 and not in accordance with CDC recommendations.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,520 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Paterson
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 | ★★★★★ | 3 | 1 |
| Complete Care At Fair Lawn Edge | 2.8 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Doctors Subacute Healthcare, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.