The Madison on Marsh

Inspectors wroteBased on interview and record review the facility failed to ensure the residents had the right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care for 4 of 6 residents (Residents #2, #20, #27 and #73) reviewed for Resident Rights. The facility failed to ensure Residents #2, #20, #27 and #73, and/or the resident's representative were invited and given the opportunity to participate in the resident's care plan meetings. This failure could place residents at risk of a decline in physical health, psychosocial health, and quality of care.

Inspectors wroteBased on interview and record reviews the facility failed to ensure a facility with more than 120 beds employed a qualified social worker on a full-time basis for 1 of 1 (facility) reviewed for social worker qualifications. The facility, licensed for 125 beds, failed to employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met.

Inspectors wroteBased on interview and record review the facility failed to ensure before a resident was transferred or discharged , the facility must notify the resident and resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 6 residents (Residents #2 and #12) reviewed for discharge planning.1. The facility failed to notify Resident #2 and Resident #12, or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understood when they were transferred to the hospital.2. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person- centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 residents (Resident #1 and Resident #27) reviewed for care plans 1, The facility failed to ensure Resident #1's comprehensive care plan was developed to address the code status was changed from full code to DNR on 01/07/2026.2. The facility failed to ensure the care plan for Resident #11 was developed to address the code status was changed from full code to DNR on 01/12/26.3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #94) reviewed for accidents and supervision. The facility failed to ensure CNA A supervised Resident #94 while her bed was elevated in the air. This failure could place residents at risk for accidents and falls.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #57) reviewed for Foley catheters. The facility failed to ensure CNA B cleaned the Foley catheter and perineal area for Resident #57 during incontinence care. This failure could place residents at risk for developing urinary tract infections and skin infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it provided a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one of four residents (Resident #94) reviewed for environment. The facility failed to ensure Resident #94's environment was clean and sanitary. This failure could place residents at risk for having an unclean and unsanitary environment.

Inspectors wroteBased on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 1 of 3 residents (Resident #1) reviewed for discharge summary. The facility failed to complete a recapitulation of stay for Resident #1, who discharged to the community on 10/07/25. This failure could place residents at risk of a recapitulation of their stay being unavailable to help ensure continuity of care once they are discharged from the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan interventions for each resident consistent with the resident rights that included measurable objectives and time frames to meet the resident's medical needs identified in the comprehensive assessment for 1 (Resident #1) of 6 residents reviewed for care planning. The facility failed to care plan Resident #1's wound care order that reflected the following: Allow Pico dressing to stay 1 week, then remove and let doctor know what underlying wound look like. Text picture to [number] in the morning until 10/08/2025. This failure could affect resident care/services and may cause a delay in treatment and/or complications, infection, and poor wound healing. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 (Resident #2) of 4 residents reviewed for elopement. The facility failed to provide adequate supervision to Resident #2 and as a result, the resident eloped from the facility and was found by a passerby between 12:00 pm and 2:00 pm in front of a local store (8.9 miles) away from the facility. Resident # 2 was gone from the facility for over five and a half hours and last seen on 02/22/25 at 1:41 AM. Resident #2 was taken to a hospital on [DATE] at 2:00 PM, and a nurse from the hospital notified the facility. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility walk-in refrigerator were covered, labeled, and dated. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #1) of 5 residents reviewed for ADLs. The facility failed to ensure Resident #1 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments for four (treatment cart #1 and medication cart #2, Medication cart #3 and Medication cart 4) of 4 carts reviewed for locked drugs and biologicals. The facility failed to lock treatment Medication Cart #1, Medication Cart #2, Medication Cart #3, and Medication Cart #4 when not in use. This failures could affect residents at risk of drug diversion or misuse of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had a right to personal privacy for one of three residents (Resident #3) reviewed for personal privacy in that: CNA C failed to ensure the door to Resident #3's room was closed while she assisted in dressing Resident #3. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to a lack of privacy during their care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive assessment and quarterly review assessments for two (Resident #1 and Resident #2) of four residents were reviewed for comprehensive care plans. The facility failed to ensure the interdisciplinary team revised and reviewed the care plan after each assessment for Resident #1 and Resident #2. This failure could affect residents by placing them at risk for not having their individual needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 1(Resident #4) of 5 reviewed for pharmaceutical services The facility failed to ensure Residents #4's medication administration was administered according to the physician order. This failure placed residents at risk of not having accurate clinical records completed to indicate if a medication was administered, resulting in potential medical errors and a decline in health.

Inspectors wroteBased on interviews, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 2 of 6 residents (Resident #37 and Resident #50) reviewed for care plans. The facility did not update Resident #37's care plan to reflect goals and interventions for Hospice. The facility did not update Resident #50's care plan to reflect goals and interventions for Hospice. This failure could place residents at risk for not receiving appropriate care and intervention to meet their current needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for three (Residents #22, #36, and #59) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #22, #36, and #59. These failures could place residents at risk for equipment that is in unsafe operating condition, that could cause injury.

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 in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items were accurately labeled and dated with the received or expiration date. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the walk-in refrigerator on 12/2/2024 at 9:18 am revealed the following: -1 large zip top bag of lettuce with no received date or expiration date. - 1 large container of unidentified food sauce dated 12/1/24. There was no label description. -1 large container of unidentified yellow dessert dated 12/1/24. There was no label description. Observation of the dry storage on 12/2/2024 at 9:25 am revealed the following: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse,establish policies and procedures to investigate any such allegations for 1 (Resident #5) of 24 residents reviewed for abuse in that: LVN D failed to report Resident #5's allegation of physical abuse to the Abuse Coordinator on 10/16/23. This failure could place residents at risk of continued and unrecognized abuse which could result in emotional distress and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all alleged violations involving abuse were reported immediately to the Administrator (Abuse Coordinator), but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (Resident #5) of 24 residents reviewed for abuse in that: LVN D failed to report Resident #5's allegation of physical abuse to the Administrator (Abuse Coordinator) on 10/16/23. This failure could place residents at risk of continued and unrecognized abuse which could result in emotional distress and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a condition as diagnosed and documented in the clinical record, and the resident received behavioral interventions unless clinically contraindicated in an effort to discontinue these drugs for 1 (Resident #33) of 6 residents reviewed for unnecessary medications. The facility failed to have a documented clinical rationale by physician to disagree with Gradual Dose Reduction for Resident #33's Depakote (antipsychotic) and Lamictal (antipsychotic) medications. The facility failed to have specific behavior monitoring and side effect monitoring for Resident #33s Depakote and Lamictal medications. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration dates for 1 of 4 medication carts (Medication cart #1) reviewed for medication storage. The facility failed to have Medication Cart #1 free of expired medications. This failure could place residents at risk for increased or decreased potency of medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 (Residents #28) of three residents reviewed for infection control in that: CNA C failed to perform hand hygiene when going from dirty to clean during Resident #28's incontinent care. This failure could place residents at risk for spread of infection through cross-contamination.