Madeira Healthcare Center

Inspectors wroteBased on review of personnel records and staff interview, the facility failed to provide a qualified activities director. This had the potential to affect all of the residents residing in the facility with the exception of 14 facility- identified residents (#3, #8, #12, #36, #45, #50,#51, #62, #67, #73, #78, #81, #82, and #89 ) who did not participate in facility activities. The facility census was 91 residents.

Inspectors wrote2. Review of records for Resident #2 revealed an admission date of 12/16/22 with diagnoses including end stage renal disease, heart transplant, kidney transplant, and Alzheimer's Disease. Review of MDS dated [DATE] revealed Resident #2 had severe cognitive impairment and required assistance with activities of daily living (ADLs). Review of progress notes revealed no documentation of care conferences being performed. Interview on 03/25/25 at 1:42 P.M. Regional Director of Clinical Operations (RDCO) #200 verified the lack of documentation for care conferences as required. 3. Review of records for Resident #7 revealed an admission date of 05/27/21 with diagnoses including multiple sclerosis (MS), extended spectrum beta lactamase (ESBL) resistance, and contracture of hand. \ Review of MDS dated [DATE] revealed Resident #7 had some cognitive impairment. [...]

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to prevent food contamination. This affected one (Resident #7) of two residents observed being fed in the dining room. The facility census was 82.

Inspectors wroteBased on medical record review, observation, staff interview, and review of a facility policy, the facility failed to ensure residents were treated with dignity and respect during incontinence care by protecting a resident's private space. This affected one (#19) of three residents reviewed for dignity. The census was 87.

Inspectors wroteBased on medical record review, review of hospital documentation, staff interview, and policy review, the facility failed to timely implement pressure ulcer prevention interventions as ordered. This affected one (#002) of three residents reviewed for wounds. The facility census was 87.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to maintain adequate infection control practices during incontinence care. This affected one (#19) of one residents observed for incontinence care. The facility census was 87.

Inspectors wroteBased on observation, medical record review, staff interviews, review of a police report, and review of the facility policy, the facility failed to provide adequate supervision and implement timely interventions for exit-seeking behaviors for Resident #37, who was cognitively impaired, had a history of wandering and exit seeking behavior and who resided in a secured unit, to prevent his elopement from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #37 left the secured unit, got in a car in the parking lot which had the keys inside and drove approximately 8.2 miles away from the facility. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food was prepared, stored, and served in a manner to prevent the spread of foodborne illness. This had the potential to affect 74 out of 75 residents. The facility identified one resident (#50) who received nothing by mouth and did not receive food from the kitchen. The facility census was 75.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure trash cans in the food preparation area were covered. This had the potential to affect all 74 residents who receive meals from the kitchen. The facility identified one resident (#50) who received nothing by mouth and did not receive food from the kitchen. The facility census was 75.

Inspectors wrote4. Medical record review for Resident #21 revealed an admission on [DATE] with diagnoses including but not limited to open wound right and left lower leg, obesity, necrotizing fasciitis, depression, non pressure chronic ulcer lower leg, obstructive sleep apnea, mental disorder, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] for Resident #21 revealed an intact cognition. Review of the plan of care for Resident #21 dated [DATE] revealed Resident #21 had impaired skin integrity, or was at risk for altered skin integrity due to open wound to right and left lower leg related to necrotizing fascitits. [...]

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility contracts, the facility failed to arrange for dental services for six (#10, #21, #38, #40, #50, and #51) of seven residents reviewed for dental care. The census was 75.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were served meals in a dignified manner. This affected one (Resident #47) out of 74 residents in the facility who receive meals from the kitchen. The facility identified one resident (#50) who did not receive meals from the kitchen. The census was 75.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to ensure resident advanced directives included the required signatures and followed the wishes of the residents. This affected three residents (#1, #38, #72) of eighteen residents reviewed for advanced directives. The facility census was 75.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the ombudsman was notified of resident discharges. This affected three (Resident #25, #50, and #83) of three residents reviewed for hospitalization. The facility census was 75.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the resident and/or resident representative was notified of the facility's bed hold policy in writing upon transfer to the hospital. This affected three (Resident #25, #50, and #83) of three residents reviewed for hospitalization. The facility census was 75.

Inspectors wroteBased on medical record review, staff interviews, observations and review of the facility policy, the facility failed to conduct care planning conferences. This affected one (Resident #10) of three residents reviewed for care planning. The facility census is 75.

Inspectors wrote2. Review of the medical record for Resident #70 revealed an admission date of 01/20/22. Diagnoses included adult failure to thrive, cognitive communication deficit, need for assistance with personal care, and weakness. Review of the Resident #70's quarterly MDS asssessment revealed Resident #70 had severely impaired cognition and did not exhibit any behaviors during the assessment period. Review of Resident #70's care plan dated 03/11/22 revealed the resident had an ADL self-care performance deficit related to adult failure to thrive. Interventions included to provide limited assistance with grooming, bathing, and hygiene. Observation on 03/28/22 at 9:24 A.M. revealed Resident #70 resting in bed. Resident #70's fingernails were observed to extend approximately half of an inch beyond the finger tip. Concurrent interview with Resident #70 revealed he wanted his fingernails cut. [...]

Inspectors wroteBased on medical record review and staff interviews, the facility failed to complete weekly skin assessments as ordered by the physician. This affected two (Resident #36 and #75) of nineteen residents reviewed for skin assessments. The facility census was 75. 1. Review of the medical record for Resident #36 revealed an admission date of 01/04/19. Resident #36's medical diagnoses included cerebral palsy, diabetes mellitus, respiratory failure, history of traumatic brain injury, mood disorder, and major depressive disorder. Review of Resident #36's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitive impaired. Resident #36 required total two-person physical assist for bed mobility, transfers, toilet use, and personal hygiene, and required total dependence one-person physical assist for dressing and bathing. [...]

Inspectors wroteBased on record review, observation, resident interview, and staff interview, the facility failed to arrange for vision and hearing services. This affected one (Resident #51) of three residents reviewed for communication and sensory needs. The census was 75.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to order and implement a hand splint as documented for a resident with impaired range of motion. This affected one (Resident #38) of two residents reviewed for positioning and mobility. The census was 75.

Inspectors wroteBased on record review, observation, staff interview, and review of facility policy the facility failed to ensure fall prevention interventions were implemented according to evaluations and the care plan. This affected two (Resident #41 and #72) of five residents reviewed for accidents. The census was 75.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident oxygen tubing was dated as well as ensure handheld nebulizer (HHN) machines and continuous positive airway pressure (CPAP) machines in resident rooms had physician orders for use. This affected two (Residents #21 and #40) of two residents reviewed for respiratory care. The census was 75.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents received effective pain management and staff adequately assessed residents for pain. This affected one (Resident #40) of five residents reviewed for unnecessary medications. The census was 75.

Inspectors wrote4. Review of the medical record for Resident #82 revealed an admission date of 03/04/22 at approximately 3:00 P.M. Resident #82 discharged from the facility on 03/05/22 at approximately 12:00 P.M. Diagnoses included dementia with behavioral disturbance, difficulty in walking, type one diabetes mellitus, anxiety disorder, and weakness. Review of a nursing progress note dated 03/05/22 at 12:29 P.M. revealed Resident #82's son arrived at the facility and informed staff he was taking Resident #82 home. The nurse informed the son that Resident #82 admitted the day prior and none of her medications had arrived yet and would probably not be delivered until later in the evening. Review of the medication administration record (MAR) for March 2022 revealed Resident #82 had orders for the following routine medications: [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure appropriate indications for the use of antipsychotic medications as well as complete appropriate monitoring after starting an antipsychotic medication. This affected two (#08 and #36) of five residents reviewed for unnecessary medications. The facility census was 75.

Inspectors wrote2. Review of the medical record of Resident #82 revealed an admission date of 03/04/22 at approximately 3:00 P.M. The resident discharged from the facility on 03/05/22 at approximately 12:00 P.M. Diagnoses included dementia with behavioral disturbance, difficulty in walking, type one diabetes mellitus, anxiety disorder, and weakness. Review of a nursing progress note dated 03/05/22 at 12:29 P.M. revealed Resident #82's son arrived at the facility and informed staff he was taking Resident #82 home. The nurse informed the son that Resident #82 admitted the day prior and none of her medications had arrived yet and would probably not be delivered until later in the evening. Review of the medication administration record (MAR) for March 2022 revealed Resident #82 had orders for the following routine medications: [...]

Inspectors wroteBased on observation, staff interview, and medical record review the facility failed to ensure urinary catheter drainage bags were not stored directly on the floor. This affected one (Resident #50) of seven facility identified residents with urinary catheters. The census was 75. Findings Include: Medical record review for Resident #50 revealed an admission on [DATE] with diagnoses that included but were not limited to Alzheimer's disease, neuromuscular dysfunction of bladder, type two diabetes, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 revealed Resident #50 had impaired cognition. No behaviors were coded during the assessment period. Resident #50 had an indwelling urinary catheter. Review of the plan of care for Resident #50 dated 01/17/22 revealed Resident #50 had an indwelling catheter due to neurogenic bladder. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to have a complete water management plan to monitor for the risk, growth, and spread of Legionella. This had the potential to affect all 63 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to convey funds of residents upon discharge(discharge/death/eviction). This affected 20 (Residents #101, #102, #103. #104, #105, #106, #107, #108, #109, #110, #112, #116, #120, #121, #122, #124, #125, #126, #129, and #130) of 30 residents who discharged from the facility with remaining funds in their accounts. The facility census was 63.

Inspectors wroteBased on record review, staff and resident interview, and review of facility policy, the facility failed to treat a resident with dignity and respect when he attempted to contact the kitchen to make food choices and was hung up on three times. This affected one Resident #8 of 24 resident's reviewed for dignity during the initial pool sample of the annual survey. The facility census was 63.

Inspectors wroteBased on observation, and interview, the facility failed to serve food to residents in a homelike environment. This directly affected two (Residents #13 and #53) and had the potential to affect all 14 residents present at the time of the observation. The facility census was 63.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to accurately assess one resident's contractures with subsequent limitations in range of motion. This involved one(Resident #33) of three residents reviewed for positioning and mobility. The facility census was 63.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure that residents who were unable to feed themselves reviewed the necessary services to maintain good nutrition. This affected two (Residents #18 and #33) of six residents reviewed for nutrition. The facility census was 63.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure bed rails continued to be safe and appropriate to use when a new specialty mattress overlay was applied to the mattress. This affected one (Resident #18) of two residents reviewed for accidents. The facility census was 63.