Inspection Reports for
Complete Care At Madison, Llc

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.

Complaint NJ #: 171611, 163699, 172074. Complaints involved failure to revise care plans, medication errors, infection control lapses, and delayed therapy services.

The facility failed to revise an individual comprehensive care plan for a resident with a pressure ulcer, failed to notify transport and hospital staff of a resident's COVID-19 status, improperly administered medications including pain and psychotropic drugs, failed to maintain accurate narcotic counts and documentation, improperly stored medications with loose pills in medication carts, and delayed speech therapy evaluation for a resident.

The facility was found deficient in multiple areas including failure to enforce staff cell phone policies, incomplete transfer documentation, failure to notify receiving hospitals of isolation precautions, improper medication administration, incomplete narcotic accountability, improper medication storage, delayed laboratory testing for psychiatric medications, delayed speech therapy evaluation, and malfunctioning resident call bell systems.

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.

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.

Complaint # NJ 163368 involved a grievance filed by the resident's guardian regarding improper positioning related to a stage four pressure injury. The complaint was substantiated by observations, interviews, and record review.

The facility failed to update the care plan to include positioning instructions for a resident with a stage four pressure injury, resulting in staff not having clear guidance. Observations confirmed the resident was positioned incorrectly, and interviews revealed staff relied on verbal instructions rather than documented care plans. The facility held in-service training in response to the grievance.

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.

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 facility was found deficient in multiple areas including failure to complete significant change assessments, improper insulin administration technique, inadequate care and documentation for central venous catheters, inaccurate controlled substance accountability, insufficient monitoring of psychotropic medication use, unsanitary kitchen equipment, and incomplete medical records documentation.

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.

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 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.

The facility was found deficient in multiple areas including failure to prevent a resident from possessing a lighter and timely smoking evaluation, storage of expired medications and biologicals, improper food storage and lack of refrigerator temperature monitoring, and inconsistent use of personal protective equipment (PPE) by staff in isolation areas.