Mado Healthcare - Uptown

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to complete timely comprehensive smoking assessment for 8 (R6, R8, R9, R21, R39, R79, R89, R110) residents reviewed for smoking. This failure affected ALL 59 smoker residents in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled and dated, b.) store food at least six inches from the floor, c.) store food at least 18 inches from the ceiling, d.) sanitize kitchen equipment based on manufacturers' procedure directions. These failures have the potential to affect all 112 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to clean and disinfect reusable equipment (glucometer) in between resident's use and ensure staff performed hand hygiene in between resident's care during medication administration. The facility also failed to maintain their hot water temperatures within required parameters and failed to develop and implement a comprehensive water management plan to prevent and control the growth of Legionella and failed to establish control measures for areas at risk for Legionella growth within the facility's water system. These deficient practices have the potential to promote the growth and spread of Legionella in the facility water system and could affect all 112 residents residing in the facility. Findings Include: On 12/09/25 at 12:55 PM, surveyor requested from V1 (Administrator) their water management program for Legionella. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication error rate was less than 5% for 5 (R28, R29, R46, R103 and R116) of 16 residents reviewed for medication administration. There were 26 opportunities and 5 errors resulting in a 19.23% medication error rate.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide ADL (Activities of Daily Living) care assistance and ensure nail care was provided to one resident (R110) who is unable to carry out ADL independently of two residents reviewed for ADL in a sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to change oxygen nasal cannula and humidifier bottle as ordered for two (R11, R106) residents out of two reviewed for respiratory care in a final sample of 23. Findings Include:On 12/9/25 at 12:01 PM, Surveyor entered R11 and R106's room with V4 (Licensed Practical Nurse). R106 and R11 were not in their rooms and noted oxygen concentrators at R11 and R106's bedside not being used. R11 and R106's oxygen tubing and humidifier bottles were dated 12/1/25. V4 said they should have been changed on 12/7/25. V4 said that R11 and R106 uses oxygen as needed. On 12/10/25 at 12:57 PM, V2 (Director of Nursing) stated any respiratory tubing, and humidifier bottle are supposed to be changed every seven days and as needed. Even if it's an as needed order still needs to be changed. [...]

Inspectors wroteBased on observation, interview, record review the facility failed to properly discard a multi-dose insulin 28 days after opening for one (R86) resident and properly store multidose insulin vials that require refrigeration for one (R16) resident reviewed for medication storage and labeling in three of five medication carts and storage rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician order to provide specialized rehabilitation therapy post-fall for one (R102) resident reviewed out of a total sample of 23 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a prescribed treatment to one resident (R3). This failure affected one out of three residents reviewed for treatment services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right of the resident to be free from physical abuse in 1 (R1) of 3 residents reviewed for abuse in a sample of 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy by failing to notify the nurse on duty of a resident fall and failed to ensure that a resident was immediately assessed by a nurse after sustaining a fall. This failure effected 1 resident (R1) out of 5 residents reviewed for falls in a total sample of seven residents.

Inspectors wroteBased on interview and record review, the facility failed to protect resident's right to be free from physical abuse. This failure affected one (R1) out of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to (a) assess and document pressure ulcer characteristics and measurement on a weekly basis and (b) ensure that the orders provided by wound nurse practitioner (NP) were performed to 1 (R3) out of 3 residents reviewed for Improper nursing care.

Inspectors wroteBased on review of records and interview, the facility failures are the following: Failed to follow interventions in the care plan, review and/or revised the fall prevention care plan of 1 out of 4 residents (R1) reviewed for accidents and hazards. Failures affected 1 resident (R1) who had an incident of fall resulting to right hip/pelvic fracture that required surgery in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to have a qualified licensed nurse oversee the facility's restorative nursing program. The failure has the potential to affect all 120 residents that receive restorative programming.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure window blinds are not missing blind panels/slats in an effort to provide a homelike environment to residents. This failure affected 5 (R53, R74, R76, R82, R91) residents reviewed for homelike environment in the total sample of 57 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure oxygen signs were placed on the resident's door and failed to properly label and date oxygen tubing. This failure affects 3 residents (R86, R93, R25) and has the potential to affect all 25 residents that reside on the 5th floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the controlled drugs-count record form was not prematurely signed by in and outgoing nurses. These failures have the potential to affect all residents on the second, fourth, fifth, and six floors receiving medications. Findings Include: On 11/17/24 at 12:40 pm, on the second floor the controlled drugs- count record sheet was prematurely signed for the outgoing nurse. On 11/17/24 at 12:41 pm, surveyor inquired to V9 LPN (License Practical Nurse) why is the controlled drugs- count sheet prematurely sign for the outgoing nurse? V9 stated, I always sign for outgoing when I sign for incoming because there are no medications in there. Surveyor inquired to V9 if it is checked with the incoming nurse at the beginning and ending of each shift. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to discard an expired medication. This failure has a potential to affect one resident (R74) in a sample size of 57 residents. Findings Include: On 11/17/24 at 12:20 pm, the third-floor medication cart had R74's Breo Ellipta (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath) that was labeled to use by 11/14/24. R74's admission diagnosis includes but not limited to asthma, COPD (Chronic Obstructive Pulmonary Disease), and congestive heart failure. R74's active orders as of 11/18/24 documents in part, Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 200-25 MCG/ACT 1 puff inhale orally one time a day for Antiasthma. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an Enhanced Barrier precaution (EBP) sign is posted for a resident on EBP and failed to ensure a PPE (personal protective equipment) bin is available for resident on EBP. These failures affected 1 (R76) resident reviewed for infection control.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide functioning call device for residents requiring assistance from staff. This failure affected 2 (R91, R98) residents reviewed for resident call system in the total sample of 57 residents.

Inspectors wroteBased on interview and record review, the facility failed to establish a system of accounting for resident's funds and safeguarding resident's funds against theft, failed to follow their system of updating resident's belongings, and failed to ensure shipping address of online purchase for the resident was to the facility. These failures resulted on R1 and R6 incurring fraudulent debit card transactions on R1's and R6's bank accounts. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 03/25/2024 when V14 (R1's family member) completed a concern form regarding unexplained activities on R1's bank account. On 09/16/2024 at 10:45am, V1 was notified of the Immediate Jeopardy. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 09/23/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their own policy to conduct a complete background check of employees prior to working with residents. This failure has the potential to affect all the residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Daily Nurse Staffing was conspicuously posted in a prominent place readily accessible to residents and visitors. This failure has the potential to affect all 120 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures have the potential to affect all residents who consume food prepared by the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call light device was within reach for one resident (R19). This failure has the potential to affect one resident (R19) out of a sample of 44.

Inspectors wroteBased on observation, interview and record review the facility failed provide ADL (Activities of Daily Living) to one resident (R28) reviewed for ADL's in the sample of 44.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide supervision while shaving for one resident (R5), reviewed in a sample of 44.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication administration error rate of less than 5 percent for 2 of 7 residents (R119, R3) reviewed for medication administration. There were 33 opportunities and 3 errors resulting in a 9.09% medication administration error rate.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that expired eye medication was removed from the medication cart for one resident (R54) from a sample of 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents had a privacy curtain which extended around the bed. This failure affected three residents (R110, R421, R4) (residing in the same room) in a sample of 44 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their fall protocol by failing to re-assess a resident after a fall and failed to implement care plan interventions for one (R1) of three residents reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurately documented medical records for one (R1) of three residents reviewed for documentation of medical records.