Madison Health Care

Inspectors wroteBased on interviews and record review, the facility failed to maintain a qualified dietary manager. This had the potential to affect all 99 residents residing in the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to provide copies of a resident's medical record within two working days of the advanced notice. This affected one resident (Resident #40) of one resident who requested medical records. The census was 99.

Inspectors wroteBased on record review and interview, the facility failed to maintain a full-time social worker. This had the potential to affect all 99 residents residing in the facility.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain its dumpster area in a clean and sanitary manner. This had the potential to affect all 102 residents residing in the facility.

Inspectors wroteBased on observation, interview, review of housekeeping staffing schedules, documentation of room cleanings and facility policy review, the facility did not ensure the environment was maintained in a safe, sanitary and comfortable manner affecting 31 Residents (#1, #2, #3, #5, #7, #8, #11, #17, #18, #20, #21, #22, #23, #24, #27, #34, #37, #38, #40, #46, #56, #58, #60, #64, #66, #67, #71, #73, #81, #92, and #156) out of 102 residents observed for environment. Also, the facility had a dark unlit parking lot that had the potential to affect all 102 residents residing in the facility.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to have an individual designated closet space in the resident's bedroom which affected three residents (#17, #18, and #81) out of three residents reviewed for adequate closet space and had the potential to affect three additional residents (#2, #3, and #67) identified by the facility as sharing closet space with Residents #17, #18, and #81. The facility census was 102.

Inspectors wroteBased on resident record review, staff interviews, and facility policy review, the facility failed to report injuries of unknown origin to the state agency for Resident #69. This affected one resident (#69) of one reviewed for abuse. The facility census was 102.

Inspectors wroteBased on resident record review, staff interviews, and facility policy review, the facility failed to thoroughly investigate injuries of unknown origin for Resident #69. This affected one resident (#69) of one reviewed for abuse. The facility census was 102.

Inspectors wroteBased on interview, observation, record review and review of facility policy, the facility did not ensure Resident #71 had an order for the application and maintenance of his brace/splint to his left hand. This affected one resident (#71) out of one resident reviewed for use of a brace and/or splint. This had the potential to affect five additional residents (#24, #33, #39, #76, and #92) identified by the facility as having a brace and/or splint. The facility census was 102.

Inspectors wroteBased on observations, resident record review, resident interview, staff interviews and facility policy review, the facility failed to ensure Resident #27, identified as a fall risk, had preventative measures in place to decrease the risk of a fall. This affected one resident (#27) of three residents reviewed for falls. The facility census was 102.

Inspectors wroteBased on record review, observations, staff interviews and facility policy review, the facility failed to assess Resident #89 for oxygen titration and failed to ensure oxygen was administered with high flow oxygen tubing. Also, the facility did not ensure Residents #7 and #81 had proper signage indicating oxygen in use on the entrance to their rooms. This affected three residents (#7, #81, and #89) out of four residents reviewed for oxygen use. This had the potential to affect 22 additional residents (#24, #30, #36, #39, #46, #47, #50, #51, #52, #53, #56, #59, #60, #76, #80, #82, #88, #91, #93, #95, #156, and #254) identified by the facility with oxygen. The facility census was 102.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to ensure Resident #95 was free of significant medication error. This affected one resident (#95) out of four residents observed for medication administration. The facility census was 102.

Inspectors wroteBased on interview, record review, review of statement of expert evaluation and facility policy the facility failed to ensure Resident #103 resided in the least restrictive environment and was free from involuntary seclusion. This affected one resident (Resident #103) out of three residents reviewed for restrictive environment. The facility census was 102.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to implement care planned interventions to ensure Resident #66's open area to the crease of the left buttock and posterior thigh was identified and treated timely. This affected one resident (Resident #66) out of three residents reviewed for wounds. The facility census was 102.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #10 had effective fall interventions in place to prevent frequent falls. This affected one resident (Resident #10) out of three residents reviewed for falls. The facility census was 102.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, local police report review, and policy and procedure review the facility failed to ensure appropriate supervision to prevent a resident from leaving the facility unattended without staff knowledge. This affected one (Resident #82) of three residents reviewed for elopement. The facility census was 95.

Inspectors wroteBased on closed medical record review, review of an emergency medical transportation record, review of facility policy, and interviews, the facility failed to provide goods and services to Resident #105 to prevent an incident of neglect resulting in the resident ' s death. This resulted in Immediate Jeopardy and actual harm/death beginning on [DATE] at approximately 8:18 P.M. when Resident #105, who had advance directives for a full code status was noted to exhibit behaviors and then subsequently requested (at around 12:00 A.M. on [DATE]) the use of an as needed bronchodilator (Albuterol) inhalation medication (used to treat or prevent bronchospasm and increase air flow to lungs) without further assessment or monitoring. On [DATE] at 12:37 A.M. Resident #105 was yelling and howling in his room; at which time Licensed Practical Nurse (LPN) #410 asked the resident to close his door. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to ensure medications were administered per physician order resulting in a significant medication error. This affected one (Resident #105) of three residents reviewed for medication administration. The facility census was 103.

Inspectors wroteBased on observation, interview, and review of facility policy the facility failed to ensure food was palatable related to temperature and taste. This had the potential to affect all 103 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #86's room was clean and sanitary. This affected one resident (Resident #86) out of three residents reviewed for clean and sanitary rooms. The facility census was 103.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #86 was placed on contact precautions for Methicillin Resistant Staphylococcus Aureus (MRSA, spread by contact with infected people or things carrying the bacteria, staph bacteria resistant to common antibiotics) of her bilateral heels. This affected one resident (Resident #86) out of three reviewed for infection control. The facility census was 103.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to employ a registered nurse (RN) for at least eight consecutive hours daily who was not acting in the capacity of the Director of Nursing. This had the potential to affect all 102 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to submit payroll-based journal (PBJ) data quarterly as required. This had the potential to affect all 102 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure Resident #94's indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine) drainage bag was covered with a dignity pouch. This affected one resident (#94) out of one resident reviewed for urinary catheter use. This had the potential to affect two residents (#94 and #105) that had urinary catheters at the facility. The facility census was 102.

Inspectors wroteBased on record review and interview, the facility failed to obtain witnessed authorizations to manage resident funds. This affected three residents (#48, #67 and #98) of eight records reviewed for personal fund accounts.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #28 wore hand splints as recommended per therapy and/or the physician order. This affected one resident (#28) of one resident reviewed for range of motion (ROM). The facility census was 102.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure infection control standards were followed during dining including a resident feeding another resident utilizing the same utensil that he was using to eat with. This affected two residents (#15 and #57) out of four residents reviewed for nutrition/ hydration and had the potential to affect 35 residents (#1, #2, #3, #4, #5, #9, #12, #14, #16, #18, #19, #20, #24, #25, #29, #31, #34, #35, #40, #44, #50, #52, #57, #59, #60, #68, #75, #77, #80, #90, #91, #92, #95 #97, and #99) residing on the secured units four and five.

Inspectors wroteBased on observations, staff interview, review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH (revised 3/10/21), review of the World Health Organization (WHO) hand hygiene brochure, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure personal protective equipment (PPE) was donned for Resident #452, who was on quarantine precautions, and hand hygiene was consistently implemented to potentially prevent the spread of infections for Resident #4 while preforming wound care. This had the potential to affect all 106 residents of the facility. The facility had no active COVID-19 cases.

Inspectors wrote5. Review of the medical record for Resident #14 revealed an admission date of 5/22/20 with diagnoses including malignant neoplasm of lower respiratory tract, major depressive disorder, and hypertension. Review of the MDS 3.0 assessment, dated 06/01/21, revealed the resident had intact cognition. The resident was independent for activities of daily living. Resident #14 had an ostomy bag. Observation on 08/30/21 at 11:00 A.M. revealed Resident #14 was sitting in his wheelchair wearing a hospital gown. Further observation revealed many flies on the resident's sheets, and the bed linens were dirty. Interview on 08/30/21 at 11:06 A.M. with Licensed Practical Nurse (LPN) #69 verified that the bed linens were dirty, and there were flies in the room. This deficiency substantiates Master Complaint Number OH00114343. 3. [...]

Inspectors wroteBased on observation, staff interview and facility protocol review, the facility failed to ensure handrails were firmly secured to the wall. This affected 28 residents (Resident's #3, #4, #5, #17, #19, #24, #25, #31, #35, #42, #46, #47, #54, #55, #58, #61, #70, #71, #79, #80, #81, #82, #85, #90, #93, #94, #100, #151, #152) located on Unit 4. The facility census was 106.

Inspectors wroteBased on review of the surety bond, trial balance funds sheet and staff interview, the facility failed to provide a surety bond large enough to cover the total amount of money in all resident personal funds accounts. This had the potential to affect all 106 residents who currently resided in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to have complete and accurate care plans. This affected two (Resident's #4 and #70) of five residents reviewed for care plans. The facility census was 106.

Inspectors wroteBased on observation, record review, and guidelines for administering medication, and manufacture instructions the facility failed to administer medication according to professional standards. This affected two residents (Resident #18 and Resident #29) of five residents observed for medication administration. The facility census was 106.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #40's hair was maintained after removal of her dreadlocks. This affected one of three Residents (#4, #40, #42) reviewed for activities of daily living (ADL). The facility census was 106.

Inspectors wroteBased on record review, observations and interviews, the facility failed to complete wound care as ordered by the physician. This affected one (Resident #4) of five residents reviewed for wounds. The facility census was 106. Findings Include: Review of the medical record for Resident #4 revealed an admission date of 11/20/19 with diagnoses including morbid (severe) obesity, age-related physical debility, other neuromuscular dysfunction of the bladder, depressive episodes, type two diabetes mellitus with unspecified complications, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. The resident required extensive assistance for bed mobility and toilet use. [...]

Inspectors wroteBased on observation, medical record review and staff interviews, the facility failed to ensure Resident #3 was provided with eating equipment to maintain independence while eating. This affected one (Resident #3) of 29 residents (Resident's #3, #6, #7, #8, #10, #16, #20, #21, #26, #31, #35, #36, #38, #47, #49, #57, #60, #63, #72, #73, #74, #75, #76, #80, #83, #84, and #86) who required adaptive devices. The facility census was 106.