Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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.
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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.