Madisonville Care Center

Inspectors wroteBased on interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #46) reviewed for resident rights. The facility failed to ensure Resident#46's preference for showers were adhered to as he received a bed bath instead of a shower. This failure could place residents at risk of psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in accordance with professional standards of practice that will meet each resident's physical needs for two of two residents reviewed for insulin administration. (Resident #27 and Resident #46) A) The facility failed to ensure LVN A primed the insulin pen during insulin administration for Resident #27 on 03/18/2026. B) The facility failed to ensure LVN B primed the insulin pen during insulin administration for Resident #46 on 03/18/2026. This failure could place residents at risk of not receiving the physician ordered medication at therapeutic levels which could cause blood sugar complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents (Resident #5) reviewed for infection control practices. The facility failed to ensure CNA C and CNA D used enhanced barrier precautions during incontinent care for Resident #5 on 03/18/2026. These failure could place residents at risk for developing wounds, upper respiratory infections, and risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased on observations, interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (R#1). 1. The facility failed to ensure R#1's preferences for showers were adhered to as he was receiving a bed bath, which made him feel dirty, down, depressed, and like a prisoner. 2. The facility failed to ensure R#1 was assessed timely for safety awareness in his electric wheelchair after his last reassessment on 12/27/25. These failures could place residents at risk of psychosocial harm.

Inspectors wroteBased on interviews and record reviews, the facility failed to allow residents to make choices about aspects of his or her life in the facility that are significant to the resident for 1 of 4 (R#2) residents. The facility failed to revise R#2's care plan to reflect redirecting her whenever she was near or entering a male resident's room. These failures could place residents at risk of not receiving care and services according to their preferences.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the care and supervision to prevent accidents for 1 of 7 (Resident #1) residents reviewed for accidents and hazards. The facility failed to ensure that Resident #1, who had a history of wandering and was high risk for elopement on admission, was prevented from exiting the facility without staff supervision on 10/22/2025 and found wandering outside the facility alone approximately 20 minutes later by staff. The facility was not aware that she was not in the building when she was found. The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE] at 5:05PM. The IJ began on 10/22/2025 and ended 10/23/2025. The facility corrected the noncompliance before the survey began on 11/06/2025. [...]

Inspectors wroteBased on interviews and records review, the facility failed to ensure that medical records were accurately documented for three (3) of eight (8) residents (Resident #1, Resident #2, Resident #3) reviewed for accurate clinical records, in that: The facility failed to ensure Resident #1, Resident #2, and Resident #3's EMRs contained orders upon admission with corresponding clinical criteria to admit them to the secure unit. This deficient practice could result in errors in care and treatment and violate resident rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #172) reviewed for privacy The facility failed to ensure RN B provided privacy by drawing the privacy curtain during wound care for Resident #172. This failure could place residents at risk of a lack of privacy and not having residents rights acknowledged.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 4 residents (Residents #17 and Resident #3) reviewed for infection control, as indicated by: MA A did not clean and disinfect the blood pressure monitor while using it on residents. This failure could place the residents at risk of transmission of disease and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing and prevent new ulcers from developing for three of six residents reviewed for pressure ulcers. (Resident #52, #46, and #2) A) The facility failed to ensure Resident #52 who was admitted to the facility without pressure ulcers and was low risk for the development of pressure ulcers did not developed a Stage II pressure ulcer that progressed to a Stage IV pressure ulcer in 26 days. Once developed the facility failed to provide wound care within professional standards regarding infection control and wound cleaning techniques. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse served as the Director of Nursing on a full-time basis for one of one facility reviewed for registered nurse coverage in that: The facility failed to ensure the Director of Nursing did not serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents preventing her from providing supervision and oversight of the staff for 6 of 30 days in September 2021. These failures placed residents at risk for not having their nursing and medical needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biological medications were not past their expiration dates for two of three medication carts reviewed and one of one wound care carts reviewed and failed to ensure potential contaminants were kept off of the medication carts for 2 of 3 medication carts reviewed. The facility failed to ensure expired medications were removed from the carts and failed to ensure potential contaminants including loose pills, debris, and personal items were not on the carts. This failure could place residents at risk of not receiving the intended therapeutic benefits of their medications A) Observation on 10/03/2021 at 2:33 PM of the Nurses' med cart located on Hall A revealed Pro-Stat Sugar-free liquid supplement with no date on the bottle to indicate when it was opened. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for three of six Residents (Resident #2, #52 and #46) reviewed for pressure ulcers wound care. A) The facility failed to ensure RN A followed standard precautions during wound care for Resident #2's Stage IV coccyx pressure ulcer and Stage IV's right and left ischial pressure ulcers when he failed to perform hand hygiene, gloves changes or proper wound cleansing. [...]