Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Complete Care At Madison, Llc during CMS and state inspections, most recent first.
A resident with DM2, cirrhosis with ascites, depression, and hepatic encephalopathy had multiple meds, including insulin, diuretics, lactulose, and antidepressants, administered late on repeated occasions. The MAR audit showed several doses given well outside the ordered times, including pre-meal insulin and bedtime meds, and there was no progress note documentation explaining the delays. An LPN stated meds should be given within one hour of the scheduled time and could not explain the late administrations; the DON also stated the delays were not acceptable.
A resident receiving ADL care was left uncovered with the curtain open, the door accessible to others, and the bed left in a high position while an aide stepped out to get a brief. Two other severely cognitively impaired residents were transported in recliner chairs facing backward by an LPN and an aide, even though both staff acknowledged residents should be moved forward facing. Interviews with the LPN/UM and DON confirmed that privacy, coverage, lowered beds, and forward-facing transport were expected for resident dignity.
MDS Coding Errors for Tobacco Use and Cognitive Status: The facility inaccurately coded two residents’ MDS assessments. One resident was documented by smoking assessments and a smoking contract as a current smoker, yet the MDS marked tobacco use as no despite the resident stating they smoked and the facility identifying them as a smoker. Another resident, who was observed alert and verbal and had a BIMS score of 15/15, was coded on the admission MDS as comatose. The MDSC identified both issues as data entry errors.
Failure to Provide Needed Grooming and Nail Care: A resident who was dependent on staff for all ADLs was observed with long, jagged fingernails and facial hair on multiple occasions. The resident said they had asked staff many times to shave them and that staff had not trimmed their nails. The EMR showed severe cognitive impairment and a care plan directing staff to check and trim nails during ADL care, while the CNA, ADON, and DON acknowledged that nail care and shaving were part of routine hygiene and grooming, with no documentation of nail care found.
A resident receiving dialysis had conflicting orders for lactulose, including a standing no-lactulose order for dialysis residents and a PRN lactulose order for constipation. The MAR showed lactulose was administered, and the LPN, DON, physician, and RNC all acknowledged the conflicting orders and that the no-lactulose order should not have remained in place.
A controlled medication used for opioid dependence was found in a bag labeled for another resident, with that name crossed out, and an LPN could not explain the improper labeling. The same LPN also used correction fluid on the controlled drug record after signing the wrong date, and the UM/LPN acknowledged the bag had been reused from another resident on Methadone. The DON and CP confirmed the bag should match the resident’s medication and that correction fluid was not allowed on the controlled drug form.
Staff failed to follow contact precautions for a resident with MRSA. A PT entered the room without a gown or gloves and did not perform hand hygiene when leaving, and a CNA was also observed entering and exiting the room with a meal tray without PPE or hand hygiene. Interviews showed confusion among staff about whether the resident was on contact precautions or EBP, even though the door signage and the resident’s record indicated contact precautions were in place.
The facility failed to ensure proper narcotic count and accountability for controlled medications across multiple medication carts and shifts. Narcotic counts were not completed, and nursing signatures were missing for several shifts. Additionally, Individual Patient Controlled Substance Administration Records were incomplete for several residents. The Acting DON confirmed that the narcotic count should be completed at each shift handoff, and missing documentation is unacceptable. Furthermore, a DEA 222 form was pre-signed by the Medical Director, which is against protocol.
A facility failed to conduct timely lithium level testing for a resident with bipolar disorder, despite psychiatric recommendations. The resident, with multiple diagnoses including dementia and bipolar disorder, was on lithium carbonate. Recommendations to check lithium levels were made twice, but tests were delayed or not conducted. Facility staff did not document notifying the physician or obtaining approval for the tests, contrary to facility policies.
The facility failed to prevent staff from using cell phones and speaking non-English languages during resident care, as reported by residents during a council meeting. Residents noted that staff, including CNAs and nurses, used phones and Bluetooth earpieces while providing care, leading to medication errors. Despite awareness and policies against such practices, the facility had not taken recent disciplinary actions.
A facility failed to document complete information on the New Jersey Universal Transfer Form (UTF) for a resident with severe cognitive impairment and multiple diagnoses, including psychosis and depression, during transfers to the emergency room. The UTFs were missing critical information such as date and time of transfer, code status, and primary diagnosis. Interviews revealed no policy for completing the UTF, and staff were not required to fill out all areas of the form. Despite a policy requiring a UTF for transfers, the forms were incomplete, potentially impacting the resident's care.
A facility failed to update a resident's comprehensive care plan to include a stage 4 pressure ulcer on the right elbow. Despite having a physician's order for wound care and being on a repositioning program, the care plan only addressed potential skin integrity issues and not the actual wound. The oversight was confirmed by the UM/LPN and Acting DON, who acknowledged the care plan should have included the elbow wound. The facility lacked a specific policy for updating ICCPs.
The facility failed to follow professional standards in several cases, including not administering pain medication to a resident with chronic pain, not increasing medication doses for a resident with PTSD as ordered, using adhesive tape on a resident's gastronomy tube site against physician orders, and not notifying transport staff of a resident's COVID-19 status during transfer.
The facility failed to properly store medications, with loose, unidentifiable pills found in three medication carts. Inspections revealed two loose pills in the B-Wing's Medication Cart #2, nineteen in the C-Wing's Medication Cart #1, and six in the A-Wing's Medication Cart #1. The RN, UM/LPN, and LVN confirmed that no loose pills should be present, and it was their responsibility to maintain cart organization. The DON stated medications should be stored in their original packaging, as per the facility's policy.
A resident with severe medical conditions and impaired cognition did not receive a timely Speech Therapy evaluation despite a physician's order. The evaluation was missed due to a communication lapse between nursing staff and the Director of Rehabilitation, contrary to the facility's policy requiring prompt initiation and completion of therapy evaluations.
The facility failed to ensure the proper functioning of the resident call bell system. Observations revealed that call bell lights in several rooms did not illuminate, and the system incorrectly identified rooms, with no audible notifications at the nurse's station. The LNHA confirmed the issues, and the RCBSV was updating the system to correct these deficiencies.
Late Medication Administration for a Resident with Diabetes and Cirrhosis
Penalty
Summary
The facility failed to ensure that medications were administered within the allotted timeframe for one resident who was reviewed for medication administration times. The resident was admitted with diagnoses including alcoholic cirrhosis with ascites, type 2 diabetes mellitus with diabetic polyneuropathy, major depressive disorder, and hepatic encephalopathy. The resident’s MDS reflected intact cognition, and the care plan included diabetes medication as ordered, antidepressant use related to depression, diuretic therapy related to edema, and risk for ascites related to cirrhosis. A review of the resident’s physician orders showed scheduled administration of multiple medications, including spironolactone, furosemide, lactulose, sofosbuvir-velpatasvir, gabapentin, famotidine, duloxetine, insulin glargine-yfgn, and insulin lispro. The Medication Administration Audit Report documented repeated late administrations across multiple days in February 2026. Examples included morning doses of spironolactone, furosemide, lactulose, and sofosbuvir-velpatasvir being given more than an hour late, insulin lispro doses given well after scheduled pre-meal times, and bedtime medications such as insulin glargine-yfgn, famotidine, duloxetine, and lactulose being administered late on several occasions. The resident stated that nurses took a long time to administer morning medications and reported having diabetes and using insulin. The February progress notes contained no documentation explaining why the medications were not given as scheduled. During interview, the LPN stated medications were to be administered one hour before or one hour after the scheduled time and said insulin given an hour and a half late would be a medication error. The LPN could not explain why the resident’s medications were late. The DON stated medications should be administered within one hour of the due time, that right time is one of the five rights of medication administration, and that late medications were not acceptable. The DON also stated that if insulin was due at 9:00 PM, it could not be given at 6:51 PM.
Failure to Maintain Resident Dignity During Care and Transport
Penalty
Summary
The facility failed to provide ADL care in a dignified manner for one resident who was admitted with spastic diplegic cerebral palsy, schizoaffective disorder, and legal blindness, and whose MDS indicated severe cognitive impairment and dependence on staff for care. On 2/25/2026, the resident was observed in bed on their left side with the blankets pulled down, not covered, and the curtains not drawn while a male aide was providing care. The resident’s bed was in a high position, and the roommate was able to enter and leave the room while care was still in progress. The aide later confirmed he had left the room to get an adult brief and acknowledged he should have drawn the curtain, covered the resident, and lowered the bed before leaving. The facility also failed to ensure two residents were transported in a dignified manner. One resident, admitted with unspecified dementia and anxiety disorder and assessed as severely cognitively impaired, was observed being transported in a recliner chair facing backwards from the main activity area to the room and then returned to the activity area rear facing by an LPN. Another resident, also admitted with unspecified dementia and anxiety disorder and assessed as severely cognitively impaired and dependent for transfers, was observed being transported in a recliner chair facing backwards from the room to the main activity area by an aide. Both staff members stated residents should be transported facing forward for safety and acknowledged they should have transported the residents forward facing. Interviews with the LPN/unit manager and the DON confirmed that ADL care should be provided with privacy by pulling the curtain and closing the door, that residents should be covered for dignity, that beds should not be left in a high position, and that residents should be transported forward facing in their chairs. The facility policy on promoting and maintaining resident dignity stated that staff are to protect and promote resident rights and treat each resident with respect and dignity.
MDS Coding Errors for Tobacco Use and Cognitive Status
Penalty
Summary
The facility failed to accurately code the MDS for Resident #90, who was admitted with nicotine dependence and was identified by the facility as a smoker. During the survey, the resident stated they smoked up to four times a day and that the facility kept their cigarettes until smoking time. The resident’s most recent comprehensive MDS, which included a BIMS score of 15 out of 15, marked tobacco use as no in Section J1300, indicating the resident was assessed as a non-smoker. However, facility smoking assessments dated 7/22/25, 10/3/25, 10/23/25, and 1/23/26 documented that the resident was currently a smoker, and the resident had signed a smoking contract in September 2023. The MDSC acknowledged the tobacco-use coding was a data entry error and stated she had reviewed the resident’s documentation before submission. The facility also failed to accurately code the admission MDS for Resident #132. The resident was observed alert and verbal in the room and stated they had been at the facility for approximately three weeks. The admission record listed diagnoses including schizophrenia and bipolar disorder, and progress notes documented that the resident was alert and verbal on 1/13/26 and had a BIMS score of 15 out of 15 on 1/14/26, indicating cognitively intact status. Despite this, the admission MDS coded Section B Comatose as one, indicating the resident was in a persistent vegetative state or had no discernible consciousness. When questioned, the MDSC stated the information was entered by nursing staff, social work, and the MDSC, and later identified the coding as a data entry error.
Failure to Provide Needed Grooming and Nail Care
Penalty
Summary
The facility failed to provide necessary grooming services for a resident who was dependent on staff for all ADLs, including personal hygiene. During an initial tour, the resident was observed sitting in a wheelchair with long, jagged fingernails with sharp edges on both hands and grey, curled facial hair. The resident stated they were in bad shape and said they had asked staff many times to shave them. The resident’s EMR showed diagnoses including anemia, malaise, and muscle weakness. The quarterly MDS dated 12/9/25 indicated a BIMS score of 6 out of 15, showing severe cognitive impairment, and documented that the resident was dependent on staff for all ADLs. The comprehensive care plan included an ADL self-care performance deficit related to impaired balance and directed staff to check nail length and trim and clean nails on bath day and as necessary. On subsequent observations, the resident continued to have long, jagged fingernails and facial hair. The resident stated that a CNA had said she would trim the nails sometime that day and later stated they had tried to do their left-hand nails themselves because staff did not want them to. During interview, the CNA stated nail care and shaving would be provided during bed bath and/or shower and that nail care was important for hygiene. The ADON stated CNAs should check nails daily during care and confirmed there was no documentation for nail care, while also observing that the resident’s fingernails and facial hair needed to be trimmed. The DON stated hygiene was important for infection control and presentation and that staff were expected to provide nail care and shaving assistance at the resident’s request and as needed.
Conflicting Lactulose Orders Were Not Clarified for a Dialysis Resident
Penalty
Summary
The facility failed to clarify conflicting physician orders for lactulose for a resident who received dialysis on Monday, Wednesday, and Friday mornings. The resident had diagnoses including end stage renal disease, type 2 diabetes mellitus, and gastrointestinal hemorrhage, and had a Brief Mental Status score of 15 out of 15 on the quarterly MDS, indicating no cognitive impairment. The care plan included interventions for constipation, regular bowel movements, bowel habits, and hemodialysis related to renal failure. The order summary showed a standing order for no lactulose for dialysis residents, a dialysis schedule order, and a separate PRN order for lactulose for constipation. The MAR documented administration of PRN lactulose, and the LPN confirmed the medication was given while also stating the no-lactulose order did not appear on the MAR and should not have been there. The DON stated the no-lactulose order came in as a batch admission order and acknowledged it conflicted with the lactulose order. The physician stated he did not typically order lactulose based on loose bowel movements causing dehydration and later confirmed he did order the PRN lactulose. The RNC stated the no-lactulose batch order should have been discontinued upon admission by the nurse who reconciled the orders with the physician.
Methadone Storage and Controlled Drug Record Errors
Penalty
Summary
The facility failed to ensure a controlled medication, Methadone used for opioid dependence treatment, was stored with appropriate labeling and that the corresponding controlled drug sheet was altered properly for one of three medication carts inspected. During an inspection of the B wing front hall medication cart, the surveyor observed four Methadone liquid bottles labeled for one resident placed in a cellophane bag that had another resident’s name crossed out with pen. The LPN present acknowledged the label was not for the resident whose Methadone was in the bag and could not explain why the bag was not properly labeled. When the surveyor requested the corresponding controlled drug sheet for the Methadone, the LPN removed the Chain of Custody Record/External Facility from a binder and signed the form. The surveyor then observed the LPN go to the nursing station, return with white correction fluid, and cover her signature on the form. The LPN stated she had mistakenly signed for the wrong date and believed correction fluid could be used on controlled drug records. The UM/LPN later reviewed the form and acknowledged the correction fluid was present on the record under the section for the staff member administering the dose. The UM/LPN explained that she had picked up the Methadone weekly from the clinic and that the form was used to keep inventory and document administration. She also reviewed the medication bag and acknowledged it had been reused from another resident who was also on Methadone, with that resident’s name crossed out and the bag used to store the current resident’s bottles. The DON and CP later confirmed that the bag should match the resident’s medication and that correction fluid was not allowed on the controlled drug form. The resident involved had an active order for Methadone HCl oral concentrate for opioid dependence, and another resident also had an active Methadone order.
Failure to Follow Contact Precautions and PPE Requirements
Penalty
Summary
The facility failed to ensure infection control practices were followed for a resident on transmission-based precautions for MRSA. Surveyors observed a physical therapist enter the resident’s room without wearing a gown or gloves, speak with the resident, and then exit the room without donning or doffing PPE or performing hand hygiene. When interviewed immediately afterward, the therapist acknowledged not wearing PPE and stated she was unsure whether the signage applied to the resident, believing instead that the resident was on enhanced barrier precautions because of a hand infection and IV antibiotic therapy. The resident’s record showed diagnoses including sepsis due to MSSA and acute osteomyelitis of the right hand. The care plan and physician orders reflected antibiotic therapy and contact precautions for MRSA. The room door displayed signage stating that contact and droplet precautions were in place and that staff must clean their hands before entering and when leaving, put on gloves and a gown before room entry, and discard them before room exit. Despite this signage, a CNA entered and exited the room with a meal tray without observed PPE use or hand hygiene, and later acknowledged not wearing PPE or performing hand hygiene. An LPN and the unit manager also expressed confusion about whether the resident was on enhanced barrier precautions or contact precautions, although both later confirmed the contact precaution signage should be followed. Additional interviews showed inconsistent understanding among staff and therapy personnel about the required precautions. The rehab director initially did not identify the resident as being on transmission-based precautions and later confirmed the resident was on contact precautions after reviewing the record. The infection preventionist stated the resident was on contact precautions for MRSA in the bloodstream and that staff should wear a gown and gloves before entering and remove them before exiting the room, with hand hygiene performed. Facility policies reviewed by the surveyor stated that for contact precautions, gloves and a gown are to be worn before entering the room and removed before leaving, with hand hygiene performed. The deficiency was cited because staff did not consistently follow the required PPE and hand hygiene practices for the resident’s contact precautions.
Deficiencies in Narcotic Accountability and Documentation
Penalty
Summary
The facility failed to ensure proper narcotic count and accountability for controlled medications across multiple medication carts and shifts in August 2024. During a review of the B-Wing nursing unit's Medication Cart #2, it was found that the narcotic counts were not completed for several shifts, and nursing signatures were missing for both incoming and outgoing nurses. Additionally, the Individual Patient Controlled Substance Administration Records for several residents were incomplete, with missing nurse signatures for administered doses of pain and anxiety medications. The Registered Nurse confirmed these discrepancies during the survey. Further examination of the C-Wing nursing unit's Medication Cart #1 revealed similar issues, with narcotic counts left blank for numerous shifts and missing nursing signatures. The Unit Manager/LPN acknowledged the missing documentation and confirmed that all narcotic logs should be complete. The A-Wing nursing unit's Medication Cart #1 also showed incomplete narcotic counts and pre-signed shift-to-shift count logs, which the Licensed Vocational Nurse admitted to doing inappropriately. The Acting Director of Nursing confirmed that the narcotic count should be completed at each shift handoff and that missing documentation is unacceptable. Additionally, the facility failed to properly complete DEA 222 forms, as one form was pre-signed by the Medical Director before submission, which is against protocol. The Acting DON confirmed this error, and the facility could not provide a policy regarding the completion of DEA 222 forms. The facility's Controlled Substances policy requires nursing staff to count controlled medications at the end of each shift, but it did not include guidelines for resident's declining inventory sheets.
Failure to Conduct Timely Lithium Level Testing
Penalty
Summary
The facility failed to ensure timely laboratory testing for therapeutic levels of lithium, a medication used to treat bipolar disorder, for a resident. The psychiatric recommendations to check lithium levels were made on two occasions, but the tests were not conducted promptly. The first recommendation was made on February 7, 2024, but the lithium levels were not tested until March 25, 2024. The second recommendation was made on July 31, 2024, but there was no record of the test being completed. This deficiency was identified during a review of the resident's medical records and interviews with facility staff. The resident involved had multiple diagnoses, including Parkinson's disease, dementia, generalized anxiety disorder, failure to thrive, major depressive disorder, and bipolar disorder. The resident was on medications such as lithium carbonate and fluvoxamine. Despite the psychiatric recommendations, there was no documentation that the nurses notified the physician about the need to check lithium levels, nor was there any record of the physician's agreement or disagreement with the recommendations. The facility's policies required timely laboratory services and physician notification of consultant recommendations, which were not adhered to in this case.
Staff Cell Phone Use and Language Barrier During Resident Care
Penalty
Summary
The facility failed to ensure that staff did not use their cell phones in resident care areas and while performing resident care, and also failed to ensure that staff did not speak in a non-English language while rendering care to English-speaking residents. This deficiency was identified during a Resident Council group meeting with four alert and oriented residents who reported that both certified nursing aides (CNAs) and nurses were using their phones and speaking in a foreign language during care. Two residents specifically mentioned that nurses were on their Bluetooth earpieces while preparing and administering medications, leading to incorrect medications being given, which they refused to take. The residents expressed that the facility was aware of these issues but had not taken any action to address them. The facility's Social Worker confirmed that residents had complained about staff using cell phones, and formal education had been conducted to address this issue. However, observations by the surveyor noted a CNA with a Bluetooth earpiece, and the Licensed Nursing Home Administrator (LNHA) acknowledged that the issue persisted despite reminders to staff. The facility's policy prohibited cell phone use in resident care areas, and the LNHA stated that staff were expected to speak English around English-speaking residents. Despite these policies, no disciplinary actions had been taken recently for cell phone usage, and the facility did not provide any documentation of staff write-ups for such violations.
Incomplete Documentation on Universal Transfer Form
Penalty
Summary
The facility failed to document complete and appropriate information on the New Jersey Universal Transfer Form (UTF) when transferring a resident to the emergency room. This deficiency was identified for a resident with severe cognitive impairment and multiple diagnoses, including unspecified psychosis, depressive disorder, and somatoform disorder. The resident had a history of agitation and aggressive behavior, which led to their transfer to the hospital. However, the UTFs used during these transfers were incomplete, missing critical information such as the date and time of transfer, code status, primary diagnosis, isolation precautions, and contact information for the sending facility. The surveyor's review of the facility's practices revealed that there was no policy or procedure in place for completing the UTF, and staff were not required to fill out all areas of the form, contrary to the instructions. Interviews with the Infection Preventionist/LPN and the Licensed Nursing Home Administrator (LNHA) confirmed that the staff verbally communicated with transport staff but did not ensure the UTF was fully completed. The LNHA also stated that the medical records department or unit clerk was responsible for uploading the UTF to the electronic medical record, but this was not done immediately. The facility's policy on emergency transfer or discharge, revised in December 2022, required the preparation of a universal transfer form to accompany the resident. Despite this policy, the UTFs reviewed were incomplete, indicating a failure to adhere to the established procedures. This lack of documentation and communication could potentially impact the care provided to the resident upon arrival at the hospital, as essential information was not conveyed through the UTF.
Failure to Revise Comprehensive Care Plan for Resident's Elbow Wound
Penalty
Summary
The facility failed to revise an individual comprehensive care plan (ICCP) for a resident with a right elbow wound. The deficiency was identified during a survey when it was observed that the ICCP did not include the resident's actual skin impairment or stage 4 pressure ulcer on the right elbow. The resident, who had been admitted with multiple diagnoses including a stage 3 pressure ulcer and contracture of the elbow, was on a turn and reposition program and had a physician's order for specific wound care treatments. However, the ICCP, last revised in December 2023, only addressed potential skin integrity issues related to immobility and did not reflect the current condition of the resident's elbow wound. Interviews with the Unit Manager/LPN and the Acting Director of Nursing (DON) revealed that the ICCPs were supposed to be updated daily for any changes, including wounds and skin integrity. Despite this, the ICCP for the resident in question did not include the right elbow wound, which was confirmed by both the UM/LPN and the Acting DON. The Acting DON acknowledged that the focus area for the right elbow wound should have remained active, but it was mistakenly marked as resolved when the sacrum wound healed. Additionally, the facility lacked a specific policy for updating ICCPs, relying instead on a baseline care plan policy that did not address care plan revisions.
Failure to Adhere to Professional Standards in Medication Administration and Infection Control
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice in several instances, impacting the care of multiple residents. One resident with chronic pain did not receive their scheduled dose of dilaudid at 6:00 AM, despite the medication being documented as administered. The Acting Director of Nursing (DON) later explained that the nurse did not want to wake the resident and forgot to document the medication as not given. This oversight left the resident in severe pain, as indicated by their pain level of seven on a numeric scale. Another resident with post-traumatic stress disorder did not receive increased doses of mirtazapine and prazosin as ordered by their physician. The physician had entered new orders to start the increased doses on the same evening, but the nurse did not confirm the orders until the following day. The resident reported not receiving their medications as prescribed, which was confirmed by the Acting DON. The physician had communicated the changes to the nurse, but the follow-up was not adequately managed. Additionally, a resident with a gastronomy tube had adhesive tape applied to their abdomen, contrary to a physician's order to avoid tape due to skin irritation. The resident's representative frequently observed adhesive tape on the resident's abdomen, which caused a rash. The Unit Manager confirmed the presence of adhesive tape and acknowledged that the physician's order was not followed. Furthermore, the facility failed to notify emergency transport staff and the receiving hospital of a resident's COVID-19 positive status during a transfer, as required by their outbreak plan and isolation policy. This lack of communication was confirmed by the Acting DON and Infection Preventionist, who could not provide documentation that the necessary notifications were made.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to properly store medications, as evidenced by the presence of loose, unidentifiable pills in three different medication carts. During an inspection, a surveyor observed two loose pills in the B-Wing nursing unit's Medication Cart #2, nineteen loose pills in the C-Wing nursing unit's Medication Cart #1, and six loose pills in the A-Wing nursing unit's Medication Cart #1. These pills varied in shape, color, and size, and were found in the drawers containing medication blister packages. The Registered Nurse, Unit Manager/Licensed Practical Nurse, and Licensed Vocational Nurse present during the inspections confirmed that there should be no loose pills in the medication carts and that it was the responsibility of the nurses assigned to the carts to maintain their organization and cleanliness. The Acting Director of Nursing was interviewed and stated that all medications should be stored in the packaging in which they were received, and there should be no loose pills in the medication carts. The facility's Medication Storage policy, reviewed in January 2024, mandates that all medications and biologicals be stored in a safe, secure, and orderly manner, in the packaging, containers, or other dispensing systems in which they are received. This deficiency was identified as a violation of NJAC 8:39-29.4.
Failure to Provide Timely Speech Therapy Services
Penalty
Summary
The facility failed to provide timely Speech Therapy (ST) services to a resident, identified as Resident #226, who was admitted with significant medical conditions including hemiplegia, cerebral vascular accident, hypertension, and a gastrostomy tube. The resident's comprehensive Minimum Data Set (MDS) indicated severely impaired cognition and required maximum assistance for eating. Despite a physician's order dated 7/27/24 for evaluations and treatments in Occupational Therapy (OT), Speech Therapy (ST), and Physical Therapy (PT), the resident had not received the ST evaluation by the time of the surveyor's inquiry on 8/22/24. The Director of Rehabilitation (DPT) acknowledged that the ST evaluation was missed and attributed the oversight to a lack of communication from the nursing staff during morning meetings. The facility's policy, revised in February 2020, required evaluations to be initiated within 24 hours and completed within 48 hours of the order. However, the ST evaluation was not conducted until after the surveyor's inquiry, highlighting a failure in the facility's process for managing new therapy orders. The Acting Director of Nursing (DON) confirmed that the evaluation was only completed following the surveyor's intervention.
Deficient Call Bell System Functionality
Penalty
Summary
The facility failed to ensure the proper functioning of the resident call bell system, as observed and determined by surveyors. Specifically, the call bell light outside of Resident Room A-5 did not illuminate when tested, and the system incorrectly identified the room as 0222, with no audible notification at the nurse's station. Additionally, the call bell in Resident Room A-5 (window) did not illuminate or register a signal at the nurse's station. Similar issues were observed in Resident Room A-4, where neither the door nor window call bells illuminated or provided audible notifications at the nurse's station. In Resident Room A-30, although the call bell illuminated and was correctly identified at the nurse's station, there was no audible notification. The Licensed Nursing Home Administrator confirmed the lack of audible notification and discovered that the volume was turned down. The facility's Resident Call Bell System Vendor was in the process of updating the system to correct room identification issues. These deficiencies were noted during the survey and communicated to the Licensed Nursing Home Administrator at the Life Safety Code exit conference.
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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.
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Nursing homes near Matawan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook Respiratory And Nursing Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Complete Care At Bayshore Llc | 2.9 mi | ★★★★★ | 2 | 0 |
| Anchor Care And Rehabilitation Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Careone At Holmdel | 4.1 mi | ★★★★★ | 0 | 0 |
| Preferred Care At Old Bridge, Llc | 4.1 mi | ★★★★★ | 2 | 0 |
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