Madison Post Acute

Inspectors wroteBased on interview, observation and record review the facility failed to periodically inform the residents of their rights after the resident was admitted to the facility. This failure had the potential to diminish the residents' quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dining rooms included enough space for residents to dine, and for residents to enter and exit a dining room without having to move other residents in 1 of 1 dining rooms. This failure created risk for the inability of staff to respond quickly in an emergency situation, and risk for decreased quality of life for residents unable to dine with their peers.

Inspectors wroteBased on interview and record review, the facility failed to obtain a psychotropic medication consent for 4 of 6 residents (Residents 3, 16, 72, and 77) reviewed for psychotropic medications (medication that affects the mind, altering mood, thoughts, perceptions, or behavior). This failure placed residents at risk of receiving medications without being informed of the possible risks, or side effects, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident MDS (Minimum Data Set, a required assessment tool) assessments were transmitted as required and within the required timeframes for 3 of 5 residents (Residents 4, 14 and 50) reviewed. This failure had the potential to affect facility CMI (Case Mix Index) and facility payments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Minimum Date Set (MDS-an assessment tool) were accurate for 3 of 15 residents (Residents 34, 56 and 72) reviewed for resident assessment. The failure to accurately complete MDS assessments resulted in lack of triggering and completion of Care Area Assessments (CAA -triggered by MDS responses which indicates additional assessments for specific care areas), lack of comprehensive care plan development, inaccurate facility payment, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- assessment/a federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) level I were referred for a PASRR level II and followed up on for 6 of 7 residents (Residents 2, 3, 30, 56, 72, and 77) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure development and implementation of comprehensive care plans for 7 of 14 residents (Residents 2, 11, 30, 34, 53, 72 and 77) reviewed for comprehensive care plans. These failures placed residents at risk for unmet care needs, inadequate pain interventions, unnecessary medications, skin issues, accidents, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was eight consecutive hours of Registered Nurse (RN) coverage each day. Failure to have adequate RN coverage placed residents at risk for inadequate assessment of medical conditions which could cause their health to decline. Review of the 30-day staffing pattern form, dated 05/23/2026 - 06/22/2206, documented six of the 31 days did not have eight consecutive hours of RN coverage. During an interview on 06/25/2026 10:06 AM, Staff B, Director of Nursing services, stated they were aware that they did not meet the requirement for RN coverage as they did not have enough RNs on staff. Refer to WAC 388-97-1080 (8)

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary staff were following USDA Food Code requirements for hair restraints in 1 of 1 facility kitchens. Failure of staff with facial hair to wear beard restraints created the potential for physical and biological contamination of facility food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Enhanced Barrier Precautions (EBP -infection control intervention designed to reduce transmission of multidrug-resistant organisms requiring staff to wear gowns and gloves during high-contact resident care activities) were observed for 2 of 3 residents (Resident 6 and 76) sampled for medication administration and 1 of 1 resident (Resident 47) observed during a Hoyer lift (an assistive medical device used to safely transfer residents between a bed to wheelchair) transfer. These failures placed residents at risk of infection and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to timely complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-an assessment tool) for 1 of 2 residents (Resident 53), reviewed for SCSA. This failure placed the residents at risk for delayed care planning, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards were met for 1 of 1 resident (Resident 76) sampled for intravenous (IV-into the vein) medication administration. The failure to have a physician's order for the IV flush (injecting a sterile solution to clear medications, prevent blood clots and verify the line is working) placed resident at risk for complications included blockage of line and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper assistive devices to maintain their hearing abilities for 1 of 2 residents (Resident 30) reviewed for hearing services. This failure placed the resident at risk for declined communication and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis communication documents were filled out after the resident had their dialysis appointments and returned to the facility for 1 of 1 resident (Resident 77) reviewed for dialysis. This failure placed Resident 77 at risk of inadequate or lack of assessment and documentation upon arrival back at the facility, undetected dialysis complications, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure routine and emergency dental services were provided for 1 of 1 resident (Resident 56) reviewed for dental services. This failure had the potential to result in infection, pain and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 7 resident rooms (Rooms 107,108, 110, 302, 305, 306, and 307) measured at least 80 square feet per resident in multiple resident rooms and at least 100 square feet in single resident rooms. Failure to ensure residents reside in rooms which met the regulatory requirements for square footage, placed them at risk for living in a physical environment too small to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 5 residents reviewed for pre-admission screening and resident review (PASRR) received the required screening for mental health needs prior to admission for (Resident 1) and screenings were updated as required for (Residents 2 and 3). This failure placed the residents at risk of not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff S) had the required qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one facility kitchens, and one of one snack/nourishment refrigerators. The failure to ensure cleanliness of the kitchen, label opened food/beverage items, wash hands, and ensure dishwashing temperature were maintained at the proper temperature. These failures placed all residents at risk for their food to be contaminated, development of food borne illnesses, and consuming spoiled food.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place that ensured grievances were addressed and resolved in response to residents' verbal conveyance of concerns for 1 of 1 Resident Council groups and 1 of 1 sampled resident (Resident 27). The facility failed to track and investigate the concerns which led to residents repeatedly reporting the same care issues without resolution and placed them at risk of unidentified and unmet care needs, and diminished quality of life. Findings Included . Review of the undated facility policy titled Grievance Policy & Procedure, showed all grievance issues would be put into writing and brought to the Grievance Officer and would be addressed in an efficient manner. The administrator would contact the party initiating grievance to discuss and resolve any concerns. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide complete and updated Notification of Medicare Non-Coverage (NOMNC - a document informing Medicare beneficiaries that their covered services will be terminated and providing information on their appeal rights) for 4 of 4 sampled residents (Resident 4, 15, 25 and 55) reviewed for liability notice. This failure placed residents and/or their representatives at risk for not fully understanding their Medicare benefits and appeal rights and receiving inadequate information to make appeal decisions.

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility), provide a written notice to the resident and/or their representative and the ombudsman (independent and objective individual who investigates complaints against government agencies and other organizations) of a hospital transfer for 3 of 3 residents (Residents 14, 53 and 55) reviewed for hospitalization/discharge. These failures placed the residents at risk for lack of knowledge regarding their rights to a bed hold, monetary consequences, appeal rights, and available advocacy services, and possible unidentified or unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that 4 of 6 residents (Resident 3, 8, 29 and 30) reviewed for the Preadmission Screening and Resident Review (PASSR - a federally required screening of all individuals for Intellectual Disability (ID) or Related Condition and a Serious Mental Illness (SMI) prior to admission) process. The facility failed to refer the PASSRs for further review and failed to ensure any recommendations were incorporated into the plan of care. These failures placed residents at risk for unidentified mental health care needs, lack of mental health services and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the hemodialysis (medical procedure that uses a machine to filter and clean the blood when the kidneys are failing) center and consistently complete resident's pre and post dialysis assessments for 2 of 2 resident (Residents 4 and 28) reviewed for hemodialysis (HD) services. The failure of inconsistent communication and collaboration between the facility and the dialysis center about what occurred during HD and the inconsistent completion of the pre, and post dialysis assessments placed the residents at risk for unidentified medical complications and other potential/negative health outcomes.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide appetizing and palatable food to 3 of 7 residents (Residents 1, 27 and 49) reviewed for food temperature and palatability. This failure placed residents at risk for weight loss, inadequate nutrition, and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure funds were reimbursed to the resident and/or representative or the state Office of Financial Recovery (OFR) within 30 days of resident discharge or death for 1 of 4 (Resident 57) residents reviewed for trust accounts. This failure caused a delay in reconciling residents accounts within the 30 days requirement.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and/or implement individualized comprehensive care plans for 1 of 2 residents (Resident 27) reviewed for catheter use and 1 of 2 residents (Resident 8) reviewed for dementia care. Failure to develop and implement care plans that were individualized and accurately reflected resident care needs placed residents at risk of unmet care needs and potential negative outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards were met for 2 of 5 residents (Residents 3 and 30) reviewed for unnecessary medication review. The facility failed to recognize and ensure parameters were followed for blood pressure medication administration and bowel constipation protocol for the resident and failed to notify the medical provider when the resident's blood sugar levels were beyond the ordered parameters. These failures placed the residents at risk for adverse outcomes, medication errors, complications, and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with physician's orders and accepted professional standards of practice for 2 of 2 residents (Resident 49 and 6) reviewed for respiratory care. The facility failed to ensure continuous positive airway pressure (CPAP, a form of non-invasive ventilation therapy used to facilitate breathing) orders were active and in place, to include the prescribed pressure settings, checking, refilling, and cleaning of the humidifier reservoir, and identifying what solution was to be used in the humidifier. Additionally, the facility failed to ensure oxygen (O2) was being administered per physician's orders. These failures placed residents at risk for ineffective breathing, decreased oxygen levels, respiratory infection and other respiratory complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 4 residents (Resident 31) reviewed for transmission-based precautions (TBP), 1 of 4 residents (Resident 27) reviewed for bowel and bladder care, and 1 of 3 nurses (Staff F) reviewed for medication administration. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards, failed to ensure staff were compliant with appropriate hand hygiene practices during perineal care (process of cleaning genitals and anal area), and failed to ensure there was a barrier in place during medication administration. These failures placed all residents and staff at risk of potential infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 7 resident rooms (107,108, 110, 302, 305, 306, and 307) measured at least 80 square feet per resident in multiple resident rooms and at least 100 square feet in single resident rooms. Failure to ensure residents reside in rooms which met the regulatory requirements for square footage, placed them at risk for living in a physical environment too small to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor the preferences of one of one resident (Resident 26) reviewed for Activities of Daily Living. Failure to provide staff to assist Resident 26 with recreational meal intake 7 days a week placed them at risk for decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed ensure a homelike dining environment was provided during one of one dining observations. Failure to ensure licensed nurses refrained from administration of medications during resident meals placed residents at risk for diminished dignity and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure resident grievances were filed and addressed for 1 of 1 resident (Resident 11) reviewed for grievances. The failure to address and resolve resident grievances placed residents at risk for diminished dignity, unresolved missing property and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI - an assessment of a resident's needs, strengths, goals, and preferences, included thorough summaries of the Care Area Assessments, - a systematic process to interpret the triggered information from the Minimum Data Set assessment to assess the potential problem and determine if the area should be care planned), holistically analyzed the plan of care for 1 of 6 sampled residents (Resident 30) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on their individualized needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plan interventions were implemented for 1 of 3 sampled residents (Resident 13) reviewed for accidents. This failure placed residents at risk for injury, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to revise comprehensive care plans for 2 of fourteen sampled residents (Residents 3 and 20), reviewed for care plan revisions. The failure to revise care plans for dental services and discharge planning placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were implemented for 2 of fourteen residents (Residents 21 and 26) reviewed. Failure to follow physician's orders for labs and medication parameters for Resident 21 and to follow Speech Language Pathologist (SLP) recommendations for Resident 26 placed the residents at risk for delay in treatment and potentially adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living for 2 of 2 sampled dependent residents (Residents 26 and 30) reviewed for activities of daily living (ADL's). Facility failure to provide residents, who were dependent on staff for assistance with hygiene including oral care and meal assistance placed residents at risk for diminished quality of life. <RESIDENT 30> Resident 30 admitted to the facility on [DATE] with diagnoses that included fracture of the right upper leg. Review of Resident 30's Minimum Data Set (MDS-an assessment tool) dated 06/18/2024 showed they required supervision or touching assistance with eating and partial/moderate assistance to complete their oral hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being for 2 of 5 residents (Resident 21 and 30) reviewed. The facility failed to ensure Resident 21's alternating air mattress was set at the labeled setting and Resident 30 received routine repositioning. These failures placed the residents at increased risk of unmet care needs and potential skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for 1 of 4 NAC's (Staff K) files reviewed who had been employed at the facility longer than one year. This failed practice had the potential to negatively affect the competency of these NACs and the quality of care provided to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens, 1 of 1 snack/nourishment refrigerators and 2 of 3 halls observed. The failure to monitor and document safe kitchen refrigerator temperatures, label opened food/beverage items, discard expired food items in the kitchen and unit refrigerators, ensure dishwashing temperature were maintained at the proper temperature, and cover desserts during meal delivery. These failures placed all residents at risk for their food to be contaminated, development of food borne illnesses, and consuming spoiled food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adherence to infection prevention and control practices. The facility failed to properly don (put on) and doff (take off) personal protective equipment (PPE) for 1 of 1 (Resident 23) reviewed for aerosol contact precautions related to Coronavirus Disease 2019 (COVID-19, an infectious disease-causing respiratory illness symptoms including cough, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak, and failed to cover clean linens during transport. The facility also failed to properly store oxygen (O2) tubing for 1 of 1 resident (Resident 3) reviewed for O2 therapy. These failures placed residents at risk for contracting infection and diminished quality of life.

Inspectors wroteBased on record review, and interview the facility failed to develop, implement and maintain an in-service training program to ensure 1 of 4 Nursing Assistant's (Staff K) reviewed for the required 12 hour of nurse aide training per year. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training placed residents at risk for potential unmet care needs.

Inspectors wroteBased on observation and record review, the facility failed to ensure 6 resident rooms (107,108, 302, 305, 306, and 307) measured at least 80 square feet per resident in multiple resident rooms and at least 100 square feet in single resident rooms. Failure to ensure residents reside in rooms which met the regulatory requirements for square footage, placed them at risk for living in a physical environment too small to meet their needs.