Inspection Reports for Complete Care At Madison, Llc

An Initial Approval survey was conducted on 09/10/2024 for the Dialysis Den project to assess compliance with LTC-LSC regulations and life safety code requirements.

The facility was found non-compliant with emergency preparedness requirements, life safety code provisions including inadequate emergency exits, non-illuminated exit signage, lack of self-closing doors on hazardous storage rooms, and missing sprinkler protection on an awning. Corrective actions and plans of correction were documented for each deficiency.

A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including multiple complaints numbered 163503, 163699, 164917, 165994, 167427, 170365, 171611, 172074, 172747, 174114, and 175564.

Deficiencies were cited related to respect and dignity, transfer and discharge requirements, comprehensive care plans, pharmacy services, medication administration, resident call system, and life safety code violations. The facility failed to comply with multiple federal and state regulations, including improper use of cell phones by staff, incomplete universal transfer forms, inadequate medication administration, and fire safety code violations.

The visit was complaint-related with multiple complaint numbers cited. The complaints involved issues such as staff cell phone use in resident care areas, improper medication administration, incomplete transfer documentation, inadequate care planning, and fire safety violations. The complaints were substantiated as evidenced by the cited deficiencies.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.

A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers. The survey was conducted from 04/24/2023 to 04/27/2023 with a census of 132 residents.

The facility was found not in compliance with New Jersey Administrative Code and 42 CFR Part 483 requirements. Key findings included failure to maintain required staffing ratios for Certified Nurse Aides (CNAs) on multiple day shifts over several months, and failure to update and implement comprehensive care plans for residents, specifically regarding positioning and treatment of wounds for Resident #8. The facility also failed to ensure appropriate positioning to promote healing of pressure injuries.

The complaint investigation involved multiple complaint numbers (NJ00154623, NJ00155157, NJ00157573, NJ00157650, NJ00158005, NJ00158179, NJ00159719, NJ00160722, NJ00162652, NJ00163141, NJ00163368). The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on the recertification and complaint visit.

A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

The facility was found to be in substantial compliance with emergency preparedness requirements but had multiple deficiencies related to comprehensive assessment after significant change, professional standards of clinical practice, quality of care, pharmacy services, and life safety code violations including fire door inspections and emergency lighting.

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.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations as it relates to the implementation of CMS and CDC recommended practices for COVID-19.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices for COVID-19.

The inspection was conducted as a complaint survey based on complaints NJ147421 and NJ147042 regarding failure to timely notify responsible parties of resident condition changes and failure to report an injury of unknown origin to the State Survey Agency.

The facility was found not in compliance with federal regulations for long term care facilities. Deficiencies included failure to notify a resident's responsible party promptly after a fall incident and failure to report an injury of unknown origin to the State Survey Agency. The facility conducted staff in-service training and implemented monitoring logs to ensure compliance.

Complaint NJ147421 involved failure to timely notify a responsible party of a resident's fall incident. Complaint NJ147042 involved failure to report an injury of unknown origin to the State Survey Agency. Both complaints affected one resident each out of three reviewed.

The inspection was conducted as a complaint survey based on complaints NJ145326 and NJ145210.

The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.

Complaint numbers NJ145326 and NJ145210 were investigated and found to be unsubstantiated as the facility was in compliance.

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 describe their rights related to this information.

The notice outlines 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 responsibilities to protect privacy.