Inspection Reports for
The Madison Senior Living

19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: Based on record review and interview the facility failed to produce documentation that required fire drills were conducted on each shift every three months; records review showed only eight drill records on file.

19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test: Based on record review and interview the facility failed to show proof the fire alarm system was activated at least once a month; records review showed only eight activations recorded.

19 CSR 30-86.022(10)(J) Smoke Section Partitions < than 20 beds: Based on observation and interview the facility failed to ensure a fire rated separation was maintained for the attic space; an attic access door was observed hanging open exposing attic wood framing.

19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: Based on observations and interview the facility failed to ensure wastebaskets were the approved types; numerous resident rooms were observed with improper types of wastebaskets.

19 CSR 30-86.022(17) Oxygen Storage Requirements: Based on observation and interviews the facility failed to provide proper oxygen storage in accordance with NFPA 99; oxygen bottles were observed stored in a resident room.

19 CSR 30-86.032(2) Substantially Constructed & Maintained: Based on observations and interview the facility failed to maintain fire doors in good repair; one side of a fire door was not latching properly.

19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable: Based on observation and interview the facility failed to ensure the use of portable space heaters was prohibited; portable electric heaters were observed in a resident room.

19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test: Based on record review and interview the facility failed to show proof the fire alarm system was activated at least once a month; records showed no overnight activations though overnight drills were conducted and staff stated overnights are silent.

19 CSR 30-86.022(17) Oxygen Storage Requirements: Based on observation and interview the facility failed to provide a proper oxygen storage room in accordance with NFPA 99; a concentrator and six medium size oxygen bottles were observed in a resident room and the Plant Operations Director indicated plans to limit bottles and establish proper storage.

19 CSR 30-86.047(28)(J) Plan to Safeguard Residents: Based on observation, interview and record review, the facility failed to ensure a plan and ongoing review for residents' side rails for sampled residents #1, #6, and #7; documentation, physician orders and facility policy regarding side rail usage were not present.

19 CSR 30-86.047(35) Protective Oversight: Based on observation, interview and record review, the facility failed to provide protective oversight for Resident #1 with known exit-seeking behavior who was found outside unaccompanied on more than one occasion.

19 CSR 30-86.022(4)(B)(1)(2) Range Hood-After 7/11/80 & Before 10/1/00 Range Hood Extinguishing Systems.: The facility failed to maintain a hood extinguishing system in accordance with NFPA 96; the range hood system's pressure gauge was in the red and parts were needed.

19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems.: The facility failed to show proof that the complete fire alarm system had been activated at least once each month for the past year and records were missing for several months.

19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 Sprinkler Systems.: The facility failed to ensure monthly sprinkler system pressure gauge readings and valve position checks were performed or documented as required.

19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant Interior Finish and Furnishings.: The facility failed to provide documentation that curtains were certified or treated to be flame-resistant and observed curtains had tags that did not reference being flame retardant.

19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal.: The facility failed to ensure wastebaskets were solid metal or UL/FM fire-resistant types and non-approved wastebaskets were observed in multiple resident rooms.

19 CSR 30-86.047(35) Protective Oversight: Based on observation, interview, and record review, the facility failed to provide protective oversight and supervision as outlined in the resident's hospital discharge paperwork for one sampled resident who displayed self-harming behaviors. The facility census was 15 residents.