Inspection Reports for Complete Care At Madison, Llc
625 State Highway 34, Matawan, NJ, 07747
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 10, 2024, identified deficiencies related to emergency preparedness and life safety code compliance, including issues with emergency exits, exit signage, self-closing doors, and sprinkler protection. Earlier inspections showed a pattern of deficiencies involving resident care planning, medication administration, staffing levels, and fire safety, with several complaint investigations substantiating these issues. Inspectors cited recurring problems with comprehensive care plans, medication management, fire safety systems, and staffing adequacy. Complaint investigations were substantiated on multiple occasions, particularly regarding medication errors, care planning, and staff conduct, while some earlier complaints were unsubstantiated. The facility’s inspection history indicates ongoing challenges with regulatory compliance, with no clear trend of sustained improvement.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than New Jersey average
New Jersey average: 5.2 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
71% occupied
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Original Licensing
Deficiencies: 5
Date: Sep 10, 2024
Visit Reason
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.
Findings
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.
Deficiencies (5)
Failed to include Dialysis Den staff and resident needs in the emergency preparedness plan and risk assessment.
Failed to provide two exits remote from each other to minimize blockage risk in the Dialysis Den.
Emergency exit directional lights were not maintained in operating condition; exit sign not illuminated.
Hazardous storage rooms lacked self-closing doors as required.
Failed to provide automatic fire sprinkler protection to a large cloth covered awning at the Dialysis Den entrance.
Report Facts
Deficiency completion date: Oct 15, 2024
Deficiency completion date: Jan 13, 2025
Deficiency completion date: Oct 15, 2024
Deficiency completion date: Oct 1, 2024
Deficiency completion date: Oct 1, 2024
Inspection Report
Complaint Investigation
Census: 118
Capacity: 167
Deficiencies: 9
Date: Aug 27, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (9)
Facility failed to ensure staff did not use cell phones or bluetooth earpieces in resident care areas, affecting residents' dignity and respect.
Facility failed to document complete and appropriate information on New Jersey Universal Transfer Forms for residents being transferred or discharged.
Facility failed to revise individual comprehensive care plans timely and accurately for residents.
Facility failed to follow professional standards of clinical practice in administering medications, including missed doses and improper documentation.
Facility failed to provide routine and emergency drugs and biologicals under proper pharmaceutical services and controls.
Facility failed to properly store medication and maintain accurate narcotic counts and records.
Facility failed to ensure resident call bell system functioned properly and provided audible notification.
Facility failed to maintain fire safety systems including egress doors, exit signage, sprinkler system maintenance, fire alarm testing, and smoke detector sensitivity testing.
Facility failed to ensure adequate staffing and presence of assistant director of nursing as required by state regulations.
Report Facts
Census: 118
Total Capacity: 167
Complaint Numbers: 12
Deficiency Counts: 11
Staffing Ratios: 19
Medication Cart Reviews: 3
Fire Safety Audits: 5
Inspection Report
Abbreviated Survey
Census: 135
Deficiencies: 0
Date: Oct 20, 2023
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.
Findings
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.
Report Facts
Sample Size: 7
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 3
Date: Apr 27, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to maintain minimum CNA staffing ratios on multiple day shifts over several months.
Failure to update and revise comprehensive care plans timely, including failure to communicate care plan changes to staff.
Failure to ensure appropriate positioning and treatment of pressure injuries for Resident #8, potentially affecting healing.
Report Facts
Survey Census: 132
Sample Size: 31
Deficient CNA staffing shifts: 82
CNA staffing deficits: 5
CNA staffing deficits: 6
CNA staffing deficits: 5
CNA staffing deficits: 11
CNA staffing deficits: 14
CNA staffing deficits: 7
CNA staffing deficits: 6
CNA staffing deficits: 7
CNA staffing deficits: 21
Inspection Report
Routine
Census: 114
Capacity: 167
Deficiencies: 12
Date: Dec 9, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
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.
Deficiencies (12)
Facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed for Resident #36.
Facility failed to follow acceptable professional standards by not accurately administering medication to Resident #61.
Facility failed to routinely change the dressing surrounding a central venous catheter and obtain physician orders for care for Resident #14.
Facility failed to maintain accurate accountability and reconciliation of controlled drugs for Resident #162.
Facility failed to maintain required minimum direct care staff to resident ratios for day shifts as mandated by the State of New Jersey.
Facility failed to inspect fire doors annually and maintain required fire door assemblies.
Facility failed to provide battery backup emergency lighting and emergency fire alarm notification by audible and visible signals.
Facility failed to maintain sprinkler system and fire alarm system in optimal condition.
Facility failed to ensure corridor doors resist passage of smoke and maintain door hardware properly.
Facility failed to maintain medical records complete, accurate, readily accessible, and systematically organized for Resident #38.
Facility failed to monitor and document psychotropic drug use and behavioral interventions for Resident #105.
Facility failed to maintain food safety and sanitation in the kitchen, including cleaning of can opener and range burners.
Report Facts
Residents present: 114
Total licensed beds: 167
Deficient CNA staffing shifts: 14
Fire doors deficient: 9
Fire doors inspected: 40
Deficient medication storage reviews: 3
Inspection Report
Routine
Census: 110
Deficiencies: 0
Date: Aug 18, 2022
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 as it relates to the implementation of CMS and CDC recommended practices for COVID-19.
Report Facts
Sample Size: 7
Covid + In-House: 24
Inspection Report
Routine
Census: 93
Deficiencies: 0
Date: Feb 8, 2022
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.
Findings
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.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: Sep 13, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to notify responsible party of a resident's change in condition after a fall incident.
Failure to report an injury of unknown origin to the State Survey Agency within required timeframes.
Report Facts
Sample Size: 5
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Witnessed fall incident but failed to notify responsible party |
| Director of Nursing | Director of Nursing | Provided interviews and described expectations for notification and reporting |
| RN #2 | Registered Nurse | Received hospital call about resident admission and informed RN house supervisor |
| RN #3 | RN House Supervisor | Informed about resident injury by RN #2 |
| Regional Clinical Supervisor | Regional Clinical Supervisor | Interviewed regarding incident and facility investigation |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Jul 19, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145326 and NJ145210.
Complaint Details
Complaint numbers NJ145326 and NJ145210 were investigated and found to be unsubstantiated as the facility was in compliance.
Findings
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.
Report Facts
Sample Size: 9
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 describe their rights related to this information.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | Listed as NJDHSS Privacy Officer and contact person for privacy practices. |
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