PRINTED: 05/14/2020
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

315488

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________
B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

04/18/2020

STREET ADDRESS, CITY, STATE, ZIP CODE

151 MADISON AVENUE

CARE ONE AT MADISON AVENUE
(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

MORRISTOWN, NJ 07960

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 000

A covid_19 Focused Infection Control Survey
was conducted by the State Agency on 4/18/20.
The facility was found to be in compliance with
42 CFR 483.80 infection control regulations and
has implemented the CMS and Centers for
Disease Control and Prevention (CDC)
recommended practices to prepare for
COVID-19.
Total Census: 117

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Electronically Signed

(X6) DATE

05/05/2020

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 86RO11

Facility ID: NJ60921

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