Madison Grove Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, and sanitary environment for two of two sampled residents (Residents 1 and 2), when Residents 1 and 2's shared bathroom was found with approximately 50 dead gnats (term for many species of tiny, two winged flies) on the shower floor, and Resident 1 and 2's shared room had evidence of termites found on the vinyl floorings. This failure has the potential to place Residents 1 and 2's health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain eight out of nine shower beds in safe working condition when eight shower beds, which lacked the required locking pins to secure its side rails, were found in three different shower rooms (Shower Rooms at Stations 3, 4, and 1). This failure had the potential to expose 127 out of 230 residents who use the shower bed at risk for falls, or pinching injuries.

Inspectors wroteBased on observation, interviews and record review the facility failed to maintain infection control practices for four of two hundred and twenty-nine residents when: 1. Resident 40's nebulizer (a machine that turns liquid medicine into a mist to be inhaled) . An attached oxygen tubing (a plastic tube that delivers oxygen or misted medicine to the resident) has not been changed since September 1, 2025, (thirteen days past due). 2. For Resident 48, in an Enhanced Barrier Precaution (EBP - an infection control strategy used to reduce the spread of multi-drug-resistant organisms [MDROs] and prevent transmission to other residents and healthcare workers), Restorative Nursing Assistance (RNA 1) did not remove the gloves while providing care and reached out to her pocket and pulled out a walkie talkie to make a call.3. [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure the resident rights were respected for three (3) of 3 sampled residents (Resident 19, 53 and 54) when there was not contact information of state agencies posted in a manner that was accessible and understandable to residents and resident representatives on the first floor. This failure had the potential to result in Resident 19, 53 and 54 residents and resident representatives being unable to contact pertinent state agencies when needed to file a complaint. During an interview on September 15, 2025, at 8:28 AM, with Resident 19 his room, Resident 19 stated he was not aware of the location of state agency information, in case he needed to file a complaint. Resident 19 further indicated it would require staff assistance to locate the information since it had not been located on the first floor of the two-floor building. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two medication storage rooms were free of expired medical supplies. This failure had the potential to result in the use of expired medical supplies during resident care which may increased risk of infection (when germs like bacteria, virus or fungi enter the body, causing illness) to the vulnerable population. During a concurrent observation and interview on [DATE], at 10:11 AM, with Licensed Vocational Nurse (LVN 1), in the Medication Storage Room in Unit 400, there were six (6) Covid-19 Rapid Test with an expiration date of [DATE], and nine (9) Eswab Collection and transport systems (all-in-one device for collecting samples for bacterial testing) with expiration date of [DATE]. LVN 1stated the supplies were past the expiration date and posed a risk for the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 10) when a Certified Nursing Assistant (CNA 1), stood while assisting Resident 10 with breakfast on September 15, 2025. This failure had the potential to negatively affect Resident 10's self-esteem and self-worth. During a review of Resident 10's admission Record (contains demographic and medical information), the admission Record indicated the Resident 10 was admitted to the facility on [DATE], with the diagnoses that included dysphagia (difficulty swallowing), hypertension (high blood pressure) and other abnormalities of gait and mobility (difficulty walking). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care plans (personalized document that outlines healthcare support needs of an individual) for antibiotics (medicine used to treat infections) was developed for two of three sampled residents (Resident 4 and 15) .This failure had the potential to place two residents at risk for lack of planning for adverse side effects to antibiotics and unmet care needs for Residents 4 and 15.1. During a review of Resident 4's admission Record (contains demographic and medical information), it indicated Resident 4 was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (blood flow to the brain is interrupted leading to damage), candidal sepsis (fungal infection in bloodstream), and shortness of breath. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food preferences were provided for one of three sampled residents (Resident 37) reviewed for nutrition, when Resident 37 did not receive 8 ounces (oz- unit of measurement) of whole milk for lunch as indicated on Resident 37's meal ticket (a piece of paper indicating allergies, preferences, and likes/dislikes), on September 14, 2025. This failure had the potential to cause nutritional decline and unmet care needs for Resident 37. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medications were administered without errors, for one of 11 residents (Resident 247) observed for medication pass, when LVN 3 was to administer Gabapentin (an anticonvulsant medication used to treat certain types of seizures and specific kinds of nerve pain) and Valproic acid (a medication used to treat seizure disorders, the manic phase of bipolar disorder, and to prevent migraine headaches), according to the physician's orders This failure had the potential for Resident 247 medications not to be administered in the correct prescribed route by the physician and had the potential to increase Resident 247's risk for harm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. There were two medication errors observed out of a total of 27 opportunities for errors, affecting one of 11 observed residents (Residents 247), resulting in an overall medication error rate of 7.41 percent when Resident 247 had an order to receive all medication through Percutaneous Endoscopic Gastrostomy (PEG - a feeding tube that allows a person to receive nutrition through the stomach) and it was to be administered by mouth by a Licensed Vocational Nurse (LVN 3). This failure had the potential for Resident 247 medications not to be administered in the correct prescribed route by the physician and had the potential to increase the Resident 247's risk of harm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for one of 10 residents (Resident 54) reviewed for smoking, when the rain gutter (a long, hollow channel, often made of metal or plastic, attached to the edge of a roof to collect rainwater and direct it away from the buildings foundation) above the door of the smoking area was not maintained and caused a constant leak to the walkway. This failure had the potential to expose Resident 54 to unsafe walkway conditions when entering the smoking area, due to structural damages and increased the risk for falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision for one of three sampled residents (Resident1) when Resident 1, who requires a two-person assist, fell out of bed while one Certified Nursing Assistant (CNA) was repositioning the resident and providing a brief change. This failure resulted in Resident 1 sustaining intertrochanteric (thigh bone) fracture of left hip.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents when one of four residents (Resident 2)'s left knee noted with pain and fracture of the proximal left tibia (break in the long bone of the left lower leg). This failure resulted in Resident 2 a clinically compromised resident being sent to the hospital for evaluation and treatment.

Inspectors wroteBased on interview and record review the facility failed to prevent a pressure ulcer (damage to area of the skin due to pressure) from developing for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk for potential infection and pain. When the facility failed to prevent the development of a stage 3 pressure ulcer on right trochanter (hip).

Inspectors wroteBased on observation, interview and record review the facility failed to protect the resident ' s right to be free from verbal abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of three residents (Resident 1) when staff witnessed a Respiratory Therapist 1 (RT 1, a professional person who is responsible in taking care of patients who has respiratory problems) clapping loudly in Resident 1 ' s face while using foul language. This failure resulted in resident 1 ' s rights being violated and had the potential for Resident 1 to experience psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents when one of seven residents (Resident 1) noted to have swelling of the left thigh and knee. This failure contributed to Resident 1 sustaining an acute distal femur shaft fracture (sudden break in the long part of the thigh bone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation were maintained, as well as safe and sanitary practices were maintained in the kitchen when: 1. There were food crumbs and grease residue in the oven that had the potential to promote bacteria growth within this area as well as attract microorganism (small organisms which have the potential to cause disease) carrying pests. 2. The floor under the oven and stove had food crumbs and grime that had the potential to attract microorganism carrying pests. 3. There were streaks of white residue on the sides of the oven and stove that had the potential to attract microorganism carrying pests. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to discuss and provide information on advanced directives (a written statement of a person's wishes regarding medical treatment, should the person is unable to communicate with the doctor) for two of 49 sampled residents (Residents 139 and 141). This failure had the potential to cause Residents 139 and 141's values and desires related to end-of-life care not to be carried out.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for one of four residents reviewed for PASRR (Resident 61). This failure had the potential for Resident 61 not to receive the care and services most appropriate for his needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure collaboration and coordination with contracted hospice services for two of 49 sampled residents (Resident 141 and 138) when: 1. For Resident 141 there was no hospice plan of care available in the facility and there was no schedule on when skilled nursing, hospice aide, social worker or spiritual counselor visits would be conducted. 2. For Resident 138 there was no schedule on when skilled nursing, hospice aide, social worker or spiritual counselor visits would be conducted. This failure had the potential to cause Resident 141 and 138 not to receive hospice services based on a comprehensive person-centered care plan.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary treatment and services to prevent new pressures ulcers (a skin breakdown caused by prolong pressure to the skin) from developing, affecting one of seven sampled residents (Resident 27) in accordance with the facility's policy and procedure. The facility: 1. Failed to provide nursing interventions to prevent the occurrence of a new Stage 2 pressure ulcer (a Partial-thickness loss of skin with exposed muscles, presenting as a shallow open ulcer) on Resident 27's Right Shin. 2. Failed to follow through with Physical Therapy's recommendation of the use of leg splints (a brace used to prevent or treat contractures {a permanent tightening of muscle, tendon, skin, that cause the joints to shorten and become stiff}) and leg boot (used for positioning, and pressure reduction) for the Resident 27. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needed treatment and services to maintain physical function were provided for one of 49 sampled residents (Resident 21) when an order for range of motion was not renewed in a timely manner. This failure had the potential to result in negative outcomes, such as contractures and a further decline in mobility, which would negatively affect Resident 21's physical health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, a tube surgically inserted for the administration of medications and nourishment) was verified for placement and flushed prior to and after administration of medications for one of four sampled residents (Resident 31). These failures had the potential to place Resident 31 at risk for complications such as aspiration (a condition in which stomach content enter the lungs) and gastrostomy tube blockage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care of each resident was supervised by a physician and medical care needs are provided throughout the resident stay for two of 49 sampled residents (Residents 24 and 139) when: 1. For Resident 24, a licensed staff took blood pressure on the resident's right arm when Resident 24's physician's order indicated no blood pressures on the right arm. Resident 24's right arm had a non-functioning Arteriovenous Fistula (AVF, blood connection made of veins and arteries, used during hemodialysis, process of removing toxins and waste from the kidneys). This failure had the potential to affect the health and safety of the resident. 2. For Resident 139, the physician did not sign the Physician Orders for Life-Sustaining Treatment (POLST) within 30 working days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention measures for two of 213 residents (Resident 369 and 114) when: 1. A Respiratory Therapist (RT 1) did not perform hand hygiene after glove removal following a ventilator (breathing machine) check on Resident 369. 2. A Licensed Vocational Nurse (LVN 5) did not perform hand hygiene following a blood sugar check on Resident 114. These failures had the potential for cross contamination and spread of infection which can adversely affect the health and wellbeing of 213 medically compromised residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS- a facility assessment tool) assessment was submitted and completed to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for eight of eight residents reviewed for resident assessment (Residents 4, 1, 2, 82, 8, 6, 3 and 9). These failures resulted in inadequate monitoring of Residents 4, 1, 2, 82, 8, 6, 3 and 9's progress and decline, and the lack of resident specific information to CMS for payment and quality measure monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Activity programs were offered daily in accordance with the facility's policy and procedure. This failure had the potential to jeopardize the mental and psycho-social well-being of a highly vulnerable population of 222 residents, which could lead to feelings of social isolation and depression (persistent feeling of sadness and loss of interest). 2. Two of six residents reviewed for activities (Residents 52 and 66) received activities in accordance with the facility's policy and procedure when: a. For Resident 52, 27 out of 45 activity attendance participation from September 2021 to October 2021 were not offered and documented. b. For Resident 66, 22 out of 45 activity attendance participation from September 2021 to October 2021 were not offered and documented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, and sanitary food preparation, and storage practices in the kitchen when a tray of outdated tuna sandwiches were found on the shelves of the walk-in refrigerator and was available for use. This failure had the potential to cause foodborne illnesses to 181 medically compromised residents who receive food served by the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control and preventions were implemented to prevent the transmission of communicable diseases and infections among vulnerable residents in the universe of 222, when the facility: 1. Failed to ensure multi-patient use glucometer ( a device us to check blood sugar) were properly cleansed and disinfected with an approved and validated EPA (Environmental Protection Agency) disinfectant prior to use for three of 16 residents ( Residents 239, 39, and 250) requiring blood glucose testing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for 222 residents when a visitor entered the facility without proper protective equipment (PPE). This failure had the potential for the transmission of highly contagious and fatal respiratory infection COVID 19 to vulnerable residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 99) when Resident 99's urinary catheter (flexible tube inserted into the bladder to drain urine) bag, was not covered with a dignity bag (a catheter bag covering). This failure had the potential to compromise Resident 99's dignity and violates her rights to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's needs were accommodated for three of four residents (Residents 37, 118, and 237) when their call lights were not within reach. These failures had the potential to endanger their health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for three of 50 sampled residents (Residents 187, 75, and 237) when Residents 187, 75, and 237's shared bathroom had an overwhelming smell and was observed with a smeared dime-sized dried, brownish unknown substance on the floor. This failure had the potential to negatively affect Resident 187, 75, and 237's psychosocial well-being for not having a safe, clean, and homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate monitoring of anti-depressant (medication to treat depression) side effects were done for one of seven residents (Resident 178). This failure had the potential to result in a delayed diagnosis and early treatment of symptoms that can adversely affect the health and safety of Resident 178.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 49) was provided with needed care and services when Resident 49's order for physical therapy (PT- healthcare specialty that includes the evaluation, assessment, and treatment of individuals with limitations in functional mobility), occupational therapy (OT- healthcare specialty that focuses on improving one's ability to perform activities of daily living), and speech therapy (ST- assessment and treatment of communication problems and speech disorders) evaluations and treatments were not carried out as prescribed by the physician. This failure had the potential to cause contractures, and decreased mobility to Resident 49, negatively affecting her physical health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound treatment and services was provided in a timely manner for one of three residents reviewed for pressure ulcers (Resident 49). This failure had the potential to lead to worsening of the wound and delayed wound healing which would further compromise the health and welfare of Resident 49.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 56) received documented urinary catheter flushes as prescribed by the physician. This failure has the potential for Resident 56 to be at risk of urinary catheter blockage, bladder discomfort, bacteria in the urine, urinary tract infections, and even sepsis (life-threatening response to an infection which can lead to tissue damage, organ failure, and death).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided for one of two sampled residents reviewed for oxygen (Resident 131) when: 1. Resident 131's oxygen tubing was not connected from oxygen concentrator (a medical device use for delivering oxygen). (Resident 131 had an order to receive oxygen continuously.) 2. Resident 131's oxygen therapy order was not carried out as prescribed by the physician. These failures had the potential to result in a decline in Resident 131's oxygen status, causing shortness of breath, and lung damage placing Resident 131's health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order and perform self-administration of medication assessment for one of one resident (Resident 90). This failure had the potential for unexpected drug reaction, misuse, and potentially cause negative effects to the overall health of the Resident 90.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal of garbage and refuse when: a. Two soiled diapers were found on the floor by the garbage dumpsters. b. A dumpster, used for recycling, was overflowing with cardboard boxes and could not be closed completely. These failures had the potential for the harborage of insects and pests that could affect the health and safety of a highly vulnerable population of 222 residents.

Inspectors wroteBased on interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to implement and evaluate systemic measures to ensure oversight of the Nursing Department (refer to F880 Infection Prevention & Control). This failure had the potential to negatively affect the improvement of the residents' quality of care, quality of life, and safety in a highly susceptible population of 222 residents.

Inspectors wroteBased on interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to identify a systemic issue regarding proper cleaning and disinfection of glucometers by the nursing department. This failure had the potential for the facility not to be able to track problem prone areas which could negatively affect the improvement of the residents' quality of care, quality of life, and safety in a highly susceptible population of 222 residents.