Complete Care at Madison, LLC

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure medications (meds) were administered in the allotted timeframe for 1 of 1 resident (Resident #122) reviewed for medication administration times. This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) provide a resident's activities of daily living (ADL) care in a dignified manner (Resident #135) and b.) ensure residents were transported from one area of the unit to another in a dignified manner (Resident #100 and #96). This deficient practice was identified on 1 of 3 units and was evidenced by the following:1. On 2/25/2026 at 10:44 AM, the surveyor observed the door open to Resident #135s room. From the hallway, the surveyor observed the resident in bed, lying on their left side, with the blankets pulled down. The resident was not covered, and the curtains were not drawn. The resident was wearing an adult brief. The resident's bed was in a high position. At that time, the resident's roommate left the room. [...]

Inspectors wroteBased on interviews, record reviews, and review of pertinent facility documentation, it was determined that the facility failed to accurately code a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 2 of 30 residents (Resident #90 and #132) reviewed for accurately coding the MDS according to the Resident Assessment Instrument (RAI - used to assess and care plan residents). The deficient practice was evidenced by the following: 1. On 2/25/26 at 10:37 AM, during initial tour, Resident #90 was observed in their room in their bed. Resident #90 then stated that they were a smoker, and they could smoke up to four times a day. They further stated that the facility holds onto their cigarettes until it was time to smoke. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide the necessary services to maintain adequate grooming for a resident who was dependent on the staff for Activities of Daily Living (ADL). This deficient practice was observed for 1 of 1 resident (Resident #81) reviewed for ADL care. The deficient practice was evidenced by the following:On 2/25/26 at 10:28 AM, during an initial tour, the surveyor observed Resident #81 sitting in their wheelchair (w/c). The resident stated I am in bad shape while showing the surveyor both of their hands with long, jagged fingernails with sharp edges and then pointed towards their chin that had grey colored, curled up facial hair. Resident #81 stated I have asked them (the staff) to shave many times. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to clarify conflicting physician's orders for lactulose (a medication used to treat chronic constipation and hepatic encephalopathy: a brain condition caused by liver disease). The deficient practice was identified for 1 of 1 resident (Resident #5) reviewed for Dialysis and was evidenced by the following:On 2/26/2026 at 11:29 AM, the surveyor interviewed Resident #5, who stated they received dialysis in the morning on Monday, Wednesday, and Friday. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #5. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a controlled medication (Methadone)(used for opioid dependence treatment) was stored with the appropriate labeling and the coordinating controlled drug sheet (CDS)(a record of inventory) was altered appropriately for one (1) of three (3) medication carts inspected. The deficient practice was evidenced by the following: On 2/26/26 at 11:10 AM, the surveyor inspected the B wing front hall medication cart, in the presence of the Licensed Practical Nurse (LPN #1). The surveyor observed four (4) Methadone liquid bottles labeled for Resident #68 in a cellophane bag. The bag had a label with unsampled Resident #1's name crossed out with pen. LPN #1 acknowledged that the label was not for Resident #68 and was crossed out. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility records, it was determined that the facility failed to ensure infection control practices were implemented by staff not appropriately donning(put on) and doffing(remove) Personal Protective Equipment (PPE), in accordance with accepted national standards, Centers for Disease Control and Prevention (CDC) guidelines, before and after exiting a resident's room, (Resident #109), who was on Transmission Based Precautions (TBP) due to Methicillin-resistant Staphylococcus aureus (MRSA) (a type of bacteria resistant to common antibiotics that can be transmitted through direct contact) and perform hand hygiene to prevent the spread of infection, on one (1) of three (3) units . The deficient practice was evidenced by the following: According to the U.S. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure the narcotic count was completed on multiple days and shifts for August 2024 for 3 of 3 medication carts reviewed; b.) ensure accurate accountability for individual controlled medications for 3 of 3 medication carts reviewed; and c.) ensure the required Federal narcotic acquisition forms (DEA 222 forms) were dated and signed by the Medical Director as of the day it was submitted for filling for 1 of 1 forms provided. The deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure psychiatric recommendations from 2/7/24 and 7/31/24, to check therapeutic levels of medication used to treat bipolar, were obtained in a timely manner. The deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #68), and was evidenced by the following: On 8/19/24 at 11:18 AM, the surveyor observed Resident #68 sitting in the dayroom during activities. They were unable to be interviewed. On 8/22/24 at 10:08 AM, the surveyor reviewed the medical record for Resident #68. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included Parkinson's disease; dementia; generalized anxiety disorder; [...]

Inspectors wroteBased on interview and observation, it was determined that the facility failed to a.) ensure staff did not use their cell phones in resident care areas and while performing resident care; and b.) ensure staff did not speak in a non-English language while rendering care to English-speaking residents. This deficient practice was identified by 4 of 4 residents during the Resident Council group meeting (Resident #9, #14, #57, and #79) and evidenced by the following: On 8/21/24 at 10:02 AM, the surveyor conducted a resident group meeting with four residents who were alert and oriented and selected by the facility to attend the group meeting. All four residents complained that staff, both certified nursing aides (CNAs) and nurses were on their phones and some spoke in a foreign language on the phone when providing resident care. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to document complete and appropriate information on the New Jersey Universal Transfer Form (UTF) to communicate with the emergency room (ER) where a resident was being transferred, or to have a policy and procedure for UTF. This deficient practice was identified for 1 of 2 residents reviewed for hospitalization (Resident #100), and was evidenced by the following: Reference: NJ.gov: https://www.nj.gov/health/forms/hfel-7instr_1.pdf: INSTRUCTIONS FOR COMPLETING THE NEW JERSEY UNIVERSAL TRANSFER FORM dated [DATE], The purpose of the New Jersey Universal Transfer Form: A form that communicates pertinent, accurate clinical patient care information at the time of a transfer between health care facilities/programs. [...]

Inspectors wroteComplaint NJ #: 163699; 172074 Based on observation, interview, and review of facility documents, it was determined that the facility failed to follow professional standards of clinical practice with respect to a.)administering pain medications as ordered for a resident with chronic pain (Resident #48); b.) increasing the dose of two medications for a resident with post traumatic stress disorder in accordance with the physician's orders (Resident #225); c.) following a physician's order for no adhesive tape to a gastronomy feeding tube site (Resident #68); and c.) following their Outbreak Plan and Isolation policy and procedures by not notifying emergency transport staff and receiving facility staff of a resident's isolation precaution status upon the resident's (Resident #100) transfer to the emergency room (ER). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication. This deficient practice was identified in 3 of 3 medication carts inspected, and was evidenced by the following: On 8/26/24 at 9:55 AM, the surveyor, in the presence of the Registered Nurse (RN), inspected the B-Wing nursing unit's Medication Cart #2 and observed two unidentifiable, loose medication pills of varying shapes, color, and size in the bottom of the drawer containing the medication blister packages. At that time, the RN confirmed that there should be no loose pills in the medication cart, and that the nurses assigned to the cart were responsible for maintaining the organization and cleanliness of the cart and its contents. [...]

Inspectors wroteComplaint NJ #: 172074 Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to provide Speech Therapy services to a resident in a timely manner. This deficient practice was identified for 1 of 1 resident reviewed for rehabilitation (Resident #226), and was evidenced by the following: On 8/19/24 at 11:04 AM, during the initial tour of the facility, the surveyor observed Resident #226 in their room in bed. The surveyor asked the resident if they were receiving speech, physical, or occupational therapy and the resident stated not yet, but that was the plan. On 8/19/24 at 1:00 PM, the surveyor reviewed the medical record for Resident #226. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; [...]

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that the resident call bell system functioned by: a.) ensuring call bell light illuminated outside of the resident's room when pushed; b.) call bell system volume was set to a level to be heard; and c.) the call bell system accurately identified the room in need of assistance. This deficient practice was identified for 3 of 10 call bell lights tested and was evidenced by the following: On 8/21/24 at 1:45 PM, the surveyor in the presence of the Regional Maintenance Director (RMD) observed that Resident Room A-5 (door) call bell light did not illuminate outside of the resident's room when tested by the RMD. The call bell system identified the room incorrectly as 0222, and there was no audible notification at the nurse's station call bell system. [...]

Inspectors wroteComplaint NJ #:171611 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with a right elbow wound. This deficient practice was identified for 1 of 2 residents reviewed for pressure ulcer (Resident #3), and was evidenced by the following: On 8/19/24 at 11:20 AM, the surveyor observed the Certified Nursing Aide (CNA) outside Resident #3's room putting on personal protective equipment (PPE) prior to entering the room. The CNA stated that the resident was on transmission-based precautions for COVID-19, and staff were required to were PPE prior to entering the room. On 8/20/24 at 1:31 PM, the surveyor reviewed the medical record for Resident #3. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) routinely change the dressing surrounding a central venous catheter (a thin, flexible tube that is inserted into a vein, usually below the right collarbone and threaded into a larger vein above the right side of the heart), b.) obtain a Physician's Order (PO) to flush the Central Venous Catheter (CVC), and c.) develop a comprehensive care plan for the care of the CVC. This deficient practice was identified for one of one resident's reviewed, (Resident #14) for care related to a CVC. This deficient practice was evidenced by the following: On 11/28/22 at 12:39 PM, the surveyor observed Resident #14 sitting upright in bed, naked, with a sheet covering the resident's body. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care was completed. This deficient practice was identified for 1 of 27 residents reviewed, (Resident #36) for accurate completion of a significant change MDS. The deficient practice was evidenced by the following: On 11/28/22 at 10:45 AM, the surveyor observed Resident #36 lying in bed. At that time, the surveyor attempted to interview the resident. The resident was unable to verbally respond, made eye contact with the surveyor, shook his/her head and smiled. The surveyor further observed that the resident's lips and gums were pink and moist. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow acceptable professional standards of clinical practice by not accurately administering a medication, (insulin), from a prefilled pen device using the proper technique. The deficient practice was identified for one of two nurses observed during medication administration for one of four residents, (Resident #61). The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain an accurate accountability and reconciliation for two controlled drugs, (Morphine Sulfate and Fentanyl) for one resident, (Resident #162). The deficient practice was identified for one of three units reviewed for medication storage. The deficient practice was evidenced by the following: 1. On 11/29/22 at 9:46 AM, the surveyor, with the Licensed Practical Nurse (LPN), observed the controlled drugs that were locked in the refrigerator of the B unit medication storage room for inventory accountability and reconciliation. The surveyor, with the LPN, verified that there were four intravenous (IV) 250 milliliter (ML) bags containing 250 milligrams (MG) of Morphine Sulfate (MS) each were labeled for Resident #162. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to monitor a.) specific target behaviors with quantifiable data for a resident on psychotropic medications and ensure b.) non-pharmacological interventions were attempted prior to administering Seroquel (an Antipsychotic medication) as a one-time dose for a resident with agitation. This deficient practice was identified for 1 of 5 residents, (Resident #105) reviewed for unnecessary medication use. This deficient practice was evidenced by the following: On 12/1/22 at 11:09 AM, the surveyor observed Resident #105 out of bed seated at a table with two other residents and working a puzzle. The activity staff member spoke in Spanish when she conversed with the resident. The surveyor reviewed the medical record for Resident #105. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to sanitize, store, and maintain kitchen equipment to prevent microbial growth. This deficient practice was identified during the initial tour of the kitchen and was evidenced by the following: On 11/28/22 at 9:55 AM, the surveyor observed the can opener to have copious amounts of food debris and metal fragments on the blade and the body of the unit. On 11/28/22 at 10:00 AM, the surveyor observed copious amounts of accumulated food debris under the range burners without a removable tray to catch, dispose of and clean properly. On 11/28/22 at 10:10 AM, the surveyor observed the double stacked convention oven to have copious amounts of brown matter on the internal glass doors and interior of the unit. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain a complete, accurate, readily accessible, and systematically organized medical record. This deficient practice was identified for 1 of 24 residents, (Resident #38) reviewed for complete and accurate medical records and was evidenced by the following: On 11/28/2022 at 10:32 AM, the surveyor observed Resident #38 lying in bed. The surveyor interviewed the resident. During the interview the surveyor observed that the resident had discolored, jagged, and missing teeth on the top and bottom of their mouth. During an interview on 12/02/2022 at 10:45 AM, the A-wing, Licensed Practical Nurse (LPN), stated that the resident would allow staff to perform mouth care and oral hygiene, but if staff took too long performing the care, the resident would yell. [...]