Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Unclassified
Census Over Time
Inspection Report
Follow-Up
Census: 8
Deficiencies: 0
Oct 2, 2025
Visit Reason
Follow-up to the annual survey to verify correction of previously identified deficiencies.
Findings
The deficiencies identified in the prior annual survey were corrected as of the follow-up visit.
Report Facts
Census: 8
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 5
Jun 26, 2025
Visit Reason
The annual survey was conducted to assess compliance with regulatory requirements for Madison Park Healthcare, including review of incident reporting, nursing care documentation, and facility maintenance.
Findings
Deficiencies were cited related to failure to timely report major incidents, incomplete nursing documentation of visits and assessments, failure to ensure weekly nursing visits for residents with nursing needs, and inadequate housekeeping and maintenance of the facility environment.
Severity Breakdown
Class I: 1
Class II: 1
Class III: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Licensee failed to report major incidents to the Office of Health Facility Licensure and Certification within the required timeframe. | Class III |
| Registered Nurse failed to maintain a record with required documentation for each visit. | Class III |
| Registered Nurse failed to document a nursing assessment within 24 hours following admission for one resident. | Class I |
| Registered Nurse failed to see residents with nursing care needs weekly and document progress notes for two residents. | Class II |
| Facility failed to ensure adequate housekeeping and maintenance, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Resident count: 11
Residents reviewed: 11
Residents reviewed: 7
Residents reviewed: 11
Deficiency correction completion date: Aug 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to deficiencies in incident reporting, nursing documentation, and corrective actions |
| Administrator | Administrator | Involved in education and corrective action plans related to deficiencies |
| Assistant Director(s) of Nursing | Assistant Director(s) of Nursing | Involved in education, audits, and corrective action plans |
| Chief Nursing Officer | Chief Nursing Officer | Developed standardized RN visit log to ensure documentation compliance |
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 0
Jun 24, 2025
Visit Reason
Annual environmental inspection conducted to assess the facility's compliance with health and safety regulations.
Findings
No deficiencies were cited during this annual environmental inspection. The facility was found to be in compliance with applicable standards.
Report Facts
Census: 11
Deficiencies cited: 0
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 4
Aug 21, 2024
Visit Reason
Annual survey conducted from 08/19/24 to 08/21/24 to assess compliance with health and safety regulations, employee health screenings, and proper handling of resident belongings after death.
Findings
The inspection found deficiencies related to incomplete annual tuberculosis screenings for employees, inadequate documentation of resident belongings released upon death, and housekeeping and maintenance issues including damaged carpets and missing bathroom fixtures.
Severity Breakdown
Class III: 2
Class II: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure each employee's health record contained results of an annual tuberculosis screening. | Class III |
| Failed to maintain documentation that resident belongings were released to estate administrators or executors upon death. | Class III |
| Failed to ensure adequate housekeeping and maintenance, including damaged carpet, missing towel bars, toilet paper holders, and dirty sinks. | — |
| Failed to ensure employee tuberculosis tests were administered and documented properly, including missing times and dates for test readings. | Class II |
Report Facts
Census: 8
Employees reviewed: 3
Closed resident records reviewed: 4
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #7 | Named in finding for failure to have annual tuberculosis screening documented | |
| Employee #1 | Named in finding for improper tuberculosis test administration and documentation | |
| Employee #9 | Named in finding for improper tuberculosis test administration and documentation | |
| Employee #12 | Named in finding for improper tuberculosis test administration and documentation |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Aug 21, 2024
Visit Reason
Annual environmental inspection conducted to assess compliance with health and safety regulations.
Findings
No deficiencies were cited during the inspection, indicating the facility met the required standards at the time of the visit.
Report Facts
Census: 8
Deficiencies cited: 0
Inspection Report
Follow-Up
Census: 6
Deficiencies: 2
Feb 11, 2024
Visit Reason
The visit was conducted as a behavioral health survey to assess the safety and appropriateness of the environment for adolescent consumers, including a follow-up review of corrective actions.
Findings
The initial survey identified deficiencies related to inadequate supervision and unsecured doors in the adolescent residence. A follow-up review on 10/01/2024 accepted credible evidence from the facility in lieu of an onsite revisit and cleared the deficiencies.
Deficiencies (2)
| Description |
|---|
| The adolescent girls' bedrooms have outside doors without alarms or alert devices, and staff are not awake on weekend nights to monitor consumers, compromising safety. |
| An outside door in the TV room does not lock, posing a safety risk. |
Report Facts
Center census: 6
Sample size: 3
Inspection Report
Renewal
Census: 6
Deficiencies: 0
Oct 19, 2023
Visit Reason
The inspection was conducted as an annual environmental survey for license renewal of the facility.
Findings
The residence was found to be in substantial compliance with the licensing rule and all applicable Federal, State, and local Emergency Preparedness requirements. No deficiencies or tags were cited during the inspection.
Report Facts
Sample Size: 100
Census: 6
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 5
Oct 18, 2023
Visit Reason
Annual survey conducted from 10/16/23 to 10/18/23 to assess compliance with health and safety regulations, employee health records, resident records, and staff training requirements.
Findings
The facility was found deficient in maintaining complete employee health records for tuberculosis screening, incomplete resident records missing required addresses, inadequate housekeeping and maintenance in the adolescent residence, and failure to provide and document required employee orientation and annual in-service training.
Severity Breakdown
Class III: 1
Class II: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to have health records for employees containing results of pre-employment and annual tuberculosis screening. | Class III |
| Failed to list all required addresses in resident records for two residents. | — |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. | — |
| Failed to provide and maintain records of required training to new employees prior to scheduling unsupervised work within first 15 days. | Class II |
| Failed to maintain records of annual in-service training for staff on required topics including infection control and resident activities. | Class II |
Report Facts
Census: 7
Employees identified with deficient tuberculosis records: 4
Residents with incomplete address documentation: 2
Survey start date: Oct 16, 2023
Survey end date: Oct 18, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #5 | Named in tuberculosis screening and training deficiencies | |
| Employee #6 | Named in tuberculosis screening and training deficiencies | |
| Employee #14 | Named in tuberculosis screening and training deficiencies | |
| Employee #16 | Named in tuberculosis screening and training deficiencies | |
| Employee #2 | Named in annual in-service training deficiency | |
| Employee #17 | Interviewed regarding training deficiencies | |
| Director of Nursing | Director of Nursing | Interviewed regarding record deficiencies and training requirements |
| Human Resources Supervisor | Human Resources Supervisor | Responsible for auditing employee files and training compliance |
| Social Services Supervisor | Social Services Supervisor | Responsible for auditing resident records |
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 0
Dec 30, 2022
Visit Reason
Revisit to annual survey conducted at Madison Park Healthcare.
Findings
The report documents a revisit to the annual survey with a census of 11 residents. No specific deficiencies or severity levels are detailed in the provided page.
Report Facts
Census: 11
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 6
Oct 27, 2022
Visit Reason
The annual survey was conducted to assess compliance with regulatory requirements related to resident records, administrative admission and discharge, employee orientation and training, resident contracts, and facility policies.
Findings
The facility was found deficient in documenting resident dentist information, including resident bill of rights and pet policy in admission contracts, and ensuring employee training on confidentiality, specialty care, and complaint procedures. Housekeeping and maintenance issues were also noted, including damaged carpets and missing bathroom fixtures.
Deficiencies (6)
| Description |
|---|
| Failed to document the resident's dentist name, address, and phone number in the resident's record for Resident #28. |
| Failed to include assurance in the resident contract that residents shall not be held liable for undisclosed costs at admission. |
| Failed to ensure adequate housekeeping and maintenance, including damaged carpet, missing towel bars, toilet paper holders, and dirty sinks. |
| Failed to provide and maintain records of annual in-service training for employees on confidentiality, resident activities, specialty care (diabetes, pacemakers), and complaint procedures. |
| Failed to include the resident's bill of rights in the admission contract. |
| Failed to include a provision regarding pets on premises in the resident admission agreement. |
Report Facts
Census: 11
Employee identifiers: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #66 | Lacked new-hire orientation/training on complaint procedures, service plans, specialty care, policies, ombudsman's role, activities, and confidentiality. | |
| Employee #2 | Lacked training on confidentiality. | |
| Employee #3 | Lacked training on confidentiality and specialty care of diabetes. | |
| Employee #6 | Lacked training on confidentiality and specialty care of diabetes. | |
| Employee #13 | Lacked training on confidentiality, specialty care of diabetes, and pacemakers. | |
| Employee #19 | Lacked training on confidentiality, specialty care of diabetes, and pacemakers. | |
| Employee #1 | Registered Nurse/Director of Nursing | Confirmed absence of resident bill of rights and pet policy in admission contracts. |
Inspection Report
Routine
Census: 11
Deficiencies: 12
Oct 24, 2022
Visit Reason
The inspection was conducted to evaluate the physical facilities and environmental conditions of Madison Park Healthcare, focusing on cleanliness, maintenance, and compliance with health and safety regulations.
Findings
The facility failed to maintain the interior and exterior in good repair, with multiple stained ceiling tiles, black substance on a wall, and other maintenance issues observed. The facility also had housekeeping deficiencies such as personal belongings left out, carpet damage, and missing bathroom fixtures.
Deficiencies (12)
| Description |
|---|
| Stained ceiling tile in the soiled linen closet across from the vending machines. |
| Black substance on wall above the old tub room located off the shower room near the conference room. |
| Stained ceiling tile near ceiling light to the back left in the nursing station/medication room. |
| Two stained ceiling tiles in Resident Room 110. |
| Stained ceiling tile above the sink in the bathroom of Resident Room 113. |
| Miscellaneous small personal belongings behind the dresser in the girls bedroom. |
| Iron burn on the carpet. |
| Bleach spots on the carpet. |
| Chair in the living room with more than one tear (stuffing visible). |
| Upstairs bathroom missing a towel bar. |
| Bathroom missing a toilet paper holder/bar. |
| Sink was dirty and in need of cleaning. |
Report Facts
Facility census: 11
Deficiencies cited: 452
Fire Marshall Report requirements: 15
Sprinkler System Type: 13
Inspection Report
Follow-Up
Census: 11
Deficiencies: 0
Oct 24, 2022
Visit Reason
The visit was a follow-up inspection to verify correction of previously cited deficiencies.
Findings
The facility had no violations at the time of the follow-up inspection, and all previously cited deficiencies were corrected.
Report Facts
Deficiencies cited: 0
Facility census: 11
Fire Marshall Report requirements: 15
Inspection Report
Annual Inspection
Census: 9
Deficiencies: 0
Jan 4, 2022
Visit Reason
Revisit to annual inspection to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior inspection have been corrected. No additional deficiencies were found during this visit.
Report Facts
Census: 9
Inspection Report
Annual Inspection
Census: 10
Deficiencies: 13
Oct 28, 2021
Visit Reason
Annual survey conducted to assess compliance with regulatory requirements for the Assisted Living Unit at Madison Park Healthcare.
Findings
The facility failed to ensure that admission agreements included required information such as annual medical examinations, access to policies and procedures, medication handling, liability insurance, and CPR instructions. Additionally, deficiencies were found in record keeping including missing physician and dentist contact information, incomplete health assessments, and inadequate documentation related to resident deaths. The facility also failed to maintain adequate housekeeping and maintenance, with issues such as damaged carpets, missing bathroom fixtures, and unclean sinks.
Deficiencies (13)
| Description |
|---|
| Admission agreements did not specify requirements for annual medical examinations and treatment orders. |
| Admission agreements did not specify how to access the residence's policies and procedures. |
| Admission agreements did not specify medication storage, handling, distribution, and disposition. |
| Failure to release resident belongings and funds to estate administrator or executor upon death. |
| Lack of documentation of date and time of death notification to attending physician. |
| Lack of documentation of the name of the person to whom the body was released upon resident death. |
| Failure to maintain complete resident records including physician and dentist contact information. |
| Failure to maintain complete written health assessments for residents including vital signs. |
| Admission agreements did not disclose full costs including changes in care needs. |
| Admission agreements did not specify whether the residence had liability insurance coverage. |
| Resident records missing marital status information. |
| Admission agreements did not specify health and nursing care services including CPR procedures. |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bars and toilet paper holders, and unclean sinks. |
Report Facts
Facility census: 10
Deficiency count: 13
Completion dates: Dec 3, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Admission Director #36 | Admission Director | Interviewed regarding missing information in admission agreements. |
| Executive Director | Interviewed regarding awareness of admission agreement requirements and documentation. | |
| Director of Nursing #69 | Director of Nursing | Interviewed regarding missing resident records and documentation. |
| Assistant Director of Nursing #25 | Assistant Director of Nursing | Interviewed regarding missing resident records and documentation. |
| Nursing Supervisor #56 | Nursing Supervisor | Interviewed regarding missing resident records and documentation. |
| Unit Manager | Responsible for auditing resident records and corrective actions. |
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 0
Oct 27, 2021
Visit Reason
Annual environmental inspection conducted to assess compliance with health and safety regulations.
Findings
No deficiencies were cited during this annual environmental inspection.
Report Facts
Census: 11
Inspection Report
Routine
Census: 11
Deficiencies: 0
Jan 12, 2021
Visit Reason
The inspection was conducted as an Infection Control Survey at Madison Park Assisted Living facility.
Findings
No deficiencies were cited during the infection control survey conducted on January 12, 2021.
Report Facts
Census: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Adkins | Named in relation to the infection control survey |
Inspection Report
Routine
Census: 12
Deficiencies: 0
Dec 14, 2020
Visit Reason
Routine inspection visit conducted to assess compliance with health and safety regulations at Madison Park Healthcare.
Findings
The inspection found that all deficiencies were cleared at the time of the visit.
Report Facts
Census: 12
Inspection Report
Renewal
Census: 13
Deficiencies: 0
Nov 5, 2020
Visit Reason
The inspection was conducted as a license renewal survey to assess the facility's compliance with regulatory requirements.
Findings
Based on a facility tour, document review, and staff interview, the facility was found to be providing and maintaining a safe environment for residents. No deficiencies or tags were cited during the inspection.
Report Facts
Census: 13
Inspection Report
Annual Inspection
Census: 13
Deficiencies: 3
Nov 4, 2020
Visit Reason
Annual survey conducted from 11/02/20 to 11/04/20 to assess compliance with regulatory requirements for resident care and facility operations.
Findings
The facility was found deficient in ensuring service plans were completed and signed within seven days of admission for three residents, and in maintaining accurate medication administration records for two residents. Additionally, housekeeping and maintenance issues were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.
Severity Breakdown
Class I: 1
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure service plans were signed and dated by staff within seven days of admission for three residents (#2, #3, and #9). | Class II |
| Failure to keep complete medication administration records including printed name, initials, and signature of administering staff for two residents (#2 and #7). | Class I |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Census: 13
Deficient residents: 3
Deficient residents: 2
Dates of survey: Inspection conducted from 2020-11-02 to 2020-11-04
Inspection Report
Follow-Up
Census: 6
Deficiencies: 0
Mar 31, 2020
Visit Reason
Offsite revisit completed by reviewing credible evidence to verify correction of previously cited deficiencies.
Findings
All previously cited deficiencies have been cleared as of the offsite revisit on 03/31/20.
Report Facts
Center census: 6
Inspection Report
Routine
Census: 10
Deficiencies: 4
Feb 20, 2020
Visit Reason
The inspection was a routine survey conducted to assess compliance with health and safety regulations, personnel records, activities documentation, and administrative admission and discharge requirements at Madison Park Healthcare.
Findings
The facility was found deficient in maintaining complete personnel health records for tuberculosis screening, documenting duration on monthly activity calendars, and including liability insurance information in admission agreements. Additionally, housekeeping and maintenance issues were observed, such as damaged carpets, missing bathroom fixtures, and unclean areas.
Severity Breakdown
Class III: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure two employees had health records containing results of pre-employment and annual tuberculosis screening. | Class III |
| Monthly activity calendar did not list duration of activities as required. | Class III |
| Admission agreement failed to explain whether the facility provided liability insurance coverage. | Class III |
| Inadequate housekeeping and maintenance including personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Facility census: 10
Number of employees with deficient TB records: 2
Survey date: Feb 20, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #78 | Identified in deficiency for late tuberculosis screening | |
| Employee #10 | Identified in deficiency for missing tuberculosis screening record | |
| Activity Director #16 | Activity Director | Interviewed regarding activity calendar deficiencies |
| Admissions Director | Responsible for updating admission contracts and monitoring compliance | |
| Administrator | Interviewed regarding personnel records and admission agreement | |
| Human Resources Director | Responsible for ensuring TB tests are completed and recorded |
Inspection Report
Renewal
Census: 12
Deficiencies: 0
Nov 5, 2019
Visit Reason
The inspection was conducted as a license renewal survey for Madison Park Healthcare.
Findings
Based on a facility tour, staff interview, and document review, the facility was found to be in compliance and maintaining a safe environment for residents. No tags were cited during the survey.
Report Facts
Sample size: 100
Census: 12
Inspection Report
Renewal
Census: 11
Deficiencies: 1
Nov 26, 2018
Visit Reason
The document includes an Annual Licensure Survey conducted from October 23-25, 2018, followed by a Survey Follow-Up on November 26, 2018, to verify correction of deficiencies.
Findings
The Annual Licensure Survey identified deficiencies which were subsequently corrected by the time of the follow-up survey on November 26, 2018.
Deficiencies (1)
| Description |
|---|
| Deficiencies corrected as noted in the follow-up survey. |
Report Facts
Census: 11
Inspection Report
Annual Inspection
Census: 10
Deficiencies: 0
Nov 5, 2018
Visit Reason
The visit was conducted as an annual licensure survey focusing on the annual environmental conditions of the facility.
Findings
The inspection found no deficiencies cited during the annual environmental survey.
Report Facts
Census: 10
Deficiencies cited: 0
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 3
Oct 23, 2018
Visit Reason
The inspection was conducted as an Annual Licensure Survey from October 23-25, 2018 to assess compliance with health care standards and regulatory requirements at Madison Park Healthcare.
Findings
The facility was found deficient in ensuring that residents had timely, written, signed, and dated health assessments and service plans based on functional needs. Specifically, two of three residents lacked updated annual health assessments and service plans reflecting current needs, including after significant changes in condition. Additionally, housekeeping and maintenance deficiencies were noted from a prior behavioral health survey.
Severity Breakdown
CLASS II: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure each resident has a written, signed, and dated health assessment updated annually for two of three residents. | CLASS II |
| Failure to ensure service plans are based on residents' functional needs assessments for two of three residents. | CLASS II |
| Failure to ensure assessment and service plans reflect current needs and are updated after significant changes in condition for one of two applicable residents. | CLASS II |
Report Facts
Census: 11
Sample Size: 3
Days late for health assessment: 51
Days late for health assessment: 563
Completion Date for Plan of Correction: Nov 8, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding health assessment system changes | |
| Registered Nurse (RN)/Employee #3 | Interviewed regarding updating service plans after resident incidents |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Nov 27, 2017
Visit Reason
The document is an annual licensure survey conducted to assess compliance with regulatory requirements for the facility.
Findings
The annual licensure survey conducted from November 27-30, 2017 found no deficiencies cited at the facility.
Report Facts
Census: 8
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Nov 14, 2017
Visit Reason
The inspection was conducted as an annual licensure survey to assess environmental compliance at the facility.
Findings
The survey found no deficiencies or concerns; no tags were cited during the inspection.
Report Facts
Sample Size: 80
Census: 8
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 0
Dec 14, 2016
Visit Reason
The document is an annual licensure survey conducted to assess compliance with regulatory requirements for the facility.
Findings
The annual licensure survey conducted from December 12-14, 2016 found no deficiencies at the facility.
Report Facts
Census: 11
Number of Deficiencies: 0
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 12
Oct 26, 2016
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with physical facility standards and overall safety and maintenance of the residence.
Findings
The facility was found deficient in maintaining a safe, sanitary, and accident-free living environment, with multiple physical deficiencies including missing light covers, damaged call-light cords, peeling paint, stained ceiling tiles, damaged drywall, and exposed wood in various resident rooms and common areas.
Severity Breakdown
Class I: 1
Class II: 8
Deficiencies (12)
| Description | Severity |
|---|---|
| Light fixture over the sink in Resident Room 311 had missing light bulbs and no light covers. | Class I |
| Damaged call-light cord in the shower area of Resident Room 309. | — |
| Light fixture over the sink in the restroom of Resident Room 111 had no light covers. | — |
| Light fixture over the sink in the restroom of Resident Room 108 had no light covers. | — |
| Peeling paint around the top and sides of the window in Resident Room 111. | Class II |
| Stained ceiling tile in the Library on the first floor. | Class II |
| Stained ceiling tile in Resident Room 114. | Class II |
| Peeling paint on walls and peeling drywall joints on the ceiling of the Parlor/Sitting Area on the first floor. | Class II |
| Damaged and exposed drywall on walls near the shower in the Bathing Room near Resident Room 103. | Class II |
| Damaged and exposed wood on the door of the Bathing Room near Resident Room 103. | Class II |
| Stained ceiling tile in Resident Room 107. | Class II |
| Peeling stucco on the wall above the window in the Kitchen Stock Room. | Class II |
Report Facts
Deficiencies cited: 2
Census: 11
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 1
Oct 26, 2016
Visit Reason
The visit was conducted as an annual licensure survey to assess compliance with regulatory requirements.
Findings
The survey identified deficiencies related to environmental conditions, specifically citing deficiencies numbered 0252 and 0254.
Deficiencies (1)
| Description |
|---|
| Environmental deficiencies identified during the annual licensure survey. |
Report Facts
Deficiencies cited: 2
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 0
Jul 25, 2016
Visit Reason
The inspection was conducted as a complaint investigation for Complaint #00016235.
Findings
The complaint was substantiated but no deficiencies were found during the investigation.
Complaint Details
Complaint #00016235 was substantiated without deficiencies.
Report Facts
Census: 12
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 18, 2016
Visit Reason
The document is an annual licensure survey conducted to assess compliance with regulatory requirements for Madison Park Healthcare.
Findings
No survey was completed during this visit. The last survey was conducted on December 29, 2015.
Report Facts
Last survey date: Last survey completed on December 29, 2015
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 12, 2016
Visit Reason
The inspection was conducted as an annual licensure survey focusing on environmental aspects of the facility.
Findings
No deficiencies were found during the survey. Previous reports noted recommendations including 7 deficiencies and 1 critical plus 2 non-critical recommendations, but none were cited in this inspection.
Report Facts
Recommendations from prior report: 7
Sprinkler System Type: 13
Recommendations from CS report: 3
Inspection Report
Change Of Ownership
Census: 10
Deficiencies: 0
Dec 29, 2015
Visit Reason
The visit was conducted as a Change of Ownership (CHOW) Survey for Madison Park Healthcare.
Findings
The report documents the Change of Ownership survey conducted on December 28-29, 2015, with a census of 10 residents. No specific deficiencies or severity levels are detailed in the provided page.
Report Facts
Census: 10
Inspection Report
Census: 10
Deficiencies: 0
Dec 22, 2015
Visit Reason
The survey was conducted as a Change of Ownership (CHOW) environmental survey to assess the facility conditions and compliance.
Findings
No deficiencies were cited during the survey. The facility was noted to have some issues such as ceiling tiles out of place, combustibles not properly stored, and wiring maintenance concerns, but all items had been corrected as of the Fire Marshall report dated June 26, 2015.
Report Facts
Census: 10
Sprinkler Type: 13
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 0
Dec 9, 2015
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #WV00014832.
Findings
The report documents the complaint investigation conducted on December 9, 2015, with a census of 10 residents. No specific findings or deficiencies are detailed in the provided text.
Complaint Details
Complaint #WV00014832 was investigated on December 9, 2015. No substantiation status or detailed findings are provided.
Report Facts
Census: 10
Inspection Report
Annual Inspection
Census: 10
Deficiencies: 0
May 13, 2015
Visit Reason
The visit was conducted as an annual licensure survey of Madison Park Healthcare.
Findings
The report provides a summary of the annual licensure survey conducted from May 11-13, 2015, with a census of 10 residents. No specific deficiencies or severity levels are detailed in the provided document.
Report Facts
Census: 10
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 0
May 13, 2015
Visit Reason
The visit was conducted as an annual licensure survey to assess environmental conditions and compliance with regulatory standards.
Findings
The inspection found no deficiencies or technical assistance needs; the facility met all requirements during the annual licensure survey.
Report Facts
Census: 11
Deficiencies Cited: 0
Inspection Report
Annual Inspection
Census: 14
Deficiencies: 0
May 14, 2014
Visit Reason
The visit was conducted as an annual licensure survey of the facility.
Findings
The report summarizes the annual licensure survey conducted from May 12-14, 2014, with a census of 14 residents. No specific deficiencies or severity levels are detailed in the provided document.
Report Facts
Census: 14
Inspection Report
Annual Inspection
Census: 24
Deficiencies: 0
May 6, 2014
Visit Reason
The visit was conducted as an annual licensure survey of Madison Park Healthcare.
Findings
The annual licensure survey found no deficiencies at the facility.
Report Facts
Census: 24
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 0
Dec 17, 2013
Visit Reason
The inspection was conducted as a complaint investigation at Madison Park Healthcare.
Findings
The report does not provide detailed findings or deficiencies related to the complaint investigation.
Complaint Details
Complaint investigation conducted on December 17, 2013, with a census of 13 residents.
Report Facts
Census: 13
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 0
May 13, 2013
Visit Reason
The visit was conducted as an annual licensure survey of Madison Park Healthcare to assess compliance with regulatory requirements.
Findings
No deficiencies were cited during the survey, and technical assistance was provided to the facility.
Report Facts
Census: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pam Martin | HFNSII | Surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 0
May 2, 2013
Visit Reason
Annual licensure survey conducted to assess environmental conditions and compliance at Madison Park Healthcare.
Findings
No deficiencies were cited during the inspection and no technical assistance was given.
Report Facts
Census: 19
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 0
Mar 21, 2012
Visit Reason
Annual licensure survey conducted to assess environmental conditions and compliance with health and safety regulations.
Findings
No deficiencies were cited during the inspection. Technical assistance was provided to the facility.
Report Facts
Census: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Ball | Life Safety Inspector | Surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 0
Mar 14, 2012
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory standards for the facility.
Findings
No deficiencies were cited during the annual licensure survey conducted on March 13-14, 2012.
Report Facts
Census: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pam Martin | RN, HFNSII | Surveyor conducting the annual licensure survey |
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 0
Aug 3, 2011
Visit Reason
The inspection was conducted as a complaint investigation for WV#00006587 during August 3-4, 2011.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint investigation WV#00006587 was unsubstantiated.
Report Facts
Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pam Martin | RN, HFNSII | Surveyor conducting the complaint investigation |
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 0
May 10, 2011
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements.
Findings
No deficiencies or technical assistance were identified during the annual licensure survey.
Report Facts
Census: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Named in the report as associated with the annual licensure survey |
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 3
Mar 29, 2011
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with regulatory requirements related to employee screening, housekeeping, maintenance, and resident service plans.
Findings
The facility was found deficient in ensuring proper central abuse registry screening prior to hiring employees, maintaining adequate housekeeping and maintenance, and updating resident service plans to reflect current needs and significant changes in condition.
Severity Breakdown
Class II: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure that a check of the nurse aide abuse registry and central abuse registry is completed prior to hire for three employees. | Class II |
| Failure to ensure adequate housekeeping and maintenance, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. | — |
| Failure to ensure that resident service plans reflect current needs and are updated after significant changes, including lack of updates for fractured hip and wrist and missing behavioral intervention guidance. | Class II |
Report Facts
Census: 19
Sample Size: 3
Residents reviewed for service plan deficiencies: 4
Residents with deficient service plans: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SC | Licensed Practical Nurse (LPN) | Named in deficiency for lack of nurse aide abuse registry check prior to hire |
| JL | Administrator interviewed regarding employee registry checks | |
| RH | Named in deficiency for lack of nurse aide abuse registry check prior to hire | |
| JP | Named in deficiency for lack of nurse aide abuse registry check prior to hire |
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 0
Mar 28, 2011
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with regulatory requirements for the facility.
Findings
The report documents the annual licensure survey conducted on March 28-29, 2011, with a census of 19 residents. A follow-up survey was conducted on June 6, 2011, with a census of 18, during which deficiencies were corrected.
Report Facts
Census: 19
Census: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Dodrill | HFSII | Surveyor during the annual licensure survey |
| Kathy Beauchamp | HFNSII | Surveyor during the annual licensure survey |
| Pam Martin | RN, HFNSII | Surveyor during the follow-up survey |
Inspection Report
Annual Inspection
Census: 9
Deficiencies: 0
Sep 20, 2010
Visit Reason
The document reports on the Annual Licensure Survey conducted April 5-7, 2010, with follow-up surveys on July 6, 2010, and September 20, 2010, to assess compliance with licensure requirements.
Findings
The report summarizes the annual licensure survey and subsequent follow-up visits, noting census counts and surveyor involvement. Specific deficiencies are not detailed in the provided text.
Report Facts
Census: 7
Census: 9
Census: 9
Census: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW HFSII | Surveyor during Annual Licensure Survey and Deficiencies Corrected |
| Kathy Beauchamp | HFNSII | Surveyor during Annual Licensure Survey and Follow-Up Surveys |
| Ernie Chafin | HFNS II | Surveyor during Deficiencies Corrected |
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 2
Jul 6, 2010
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with healthcare standards, including medication administration and facility safety.
Findings
The facility was found deficient in ensuring medications, particularly insulin and eye drops, were administered according to physician orders. There were repeated failures in documentation and administration of insulin for multiple residents. Additionally, housekeeping and maintenance issues were noted, including damaged carpets, missing bathroom fixtures, and unclean areas.
Severity Breakdown
CLASS I: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to administer medications, including insulin and eye drops, as ordered by the physician. | CLASS I |
| Inadequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and unclean sinks. | — |
Report Facts
Census: 7
Blanks in medication administration record: 14
Blanks in medication administration record: 34
Residents potentially affected: 3
Residents potentially affected: 2
Residents potentially affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW HFSII | Surveyor during the April 5-7, 2010 annual licensure survey. |
| Kathy Beauchamp | HFNSII | Surveyor during the April 5-7, 2010 annual licensure survey and follow-up surveys. |
| Ernie Chafin | HFNS II | Surveyor during the June 7, 2010 follow-up survey. |
| Clinical Coordinator | Named in findings related to deficient medication administration. | |
| Administrator | Named in findings related to deficient medication administration. | |
| ADON | Assistant Director of Nursing | Conducted in-service training on proper insulin administration on July 6, 2010. |
| Nursing Manager | Responsible for monitoring daily records to prevent recurrence of deficient practices. |
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 3
Jun 7, 2010
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with state regulations and facility policies.
Findings
The facility was found deficient in employee orientation and training, medication administration, and housekeeping/maintenance standards. Several employees lacked documented training on key policies, and medication administration errors were noted, particularly with insulin and eye drops. Housekeeping issues included damaged carpets, missing bathroom fixtures, and cleanliness concerns.
Severity Breakdown
Class I: 1
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide and maintain records of training to new employees within 15 days of employment, including training on abuse prevention, ombudsman role, service plans, and diabetic care. | Class II |
| Failure to ensure medications, including insulin and eye drops, were administered as ordered by the physician. | Class I |
| Failure to maintain adequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and dirty sinks. | — |
Report Facts
Census: 7
Deficiencies cited: 3
Training non-compliance: 4
Medication administration blanks: 14
Medication administration blanks: 34
Blood sugar readings without insulin: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW HFSII | Surveyor involved in the Annual Licensure Survey. |
| Kathy Beauchamp | HFNSII | Surveyor involved in the Annual Licensure Survey. |
| Ernie Chafin | HFNS II | Surveyor involved in the Survey Follow-Up. |
| JM | Employee lacking documented training on ombudsman role, service plans, and policies. | |
| KH | Employee lacking documented training on ombudsman role, service plans, and policies. | |
| DB | Employee lacking documented training on ombudsman role, service plans, and policies. | |
| TF | Employee hired 5/10/2010 lacking documented training on policies, service plans, and diabetic care. | |
| JL | Assistant Administrator | Reported providing training to TF but unable to provide documentation. |
Inspection Report
Annual Inspection
Census: 10
Deficiencies: 0
Apr 21, 2010
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements for Madison Park Healthcare.
Findings
No deficiencies or technical assistance were identified during the annual licensure survey.
Report Facts
Census: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 4
Apr 7, 2010
Visit Reason
The inspection was conducted as an Annual Licensure Survey from April 5-7, 2010 to assess compliance with state regulations for assisted living facilities.
Findings
The survey identified multiple deficiencies including inadequate employee orientation and training, failure to update and provide resident admission agreements, inadequate housekeeping and maintenance, and medication administration errors including failure to follow physician orders for insulin and eye drops.
Severity Breakdown
Class I: 1
Class II: 1
Class III: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure new employees received adequate training on resident policies, abuse prevention, ombudsman role, service plans, and specialty care. | Class II |
| Failure to update resident admission agreements to include all required information and failure to provide copies to residents or legal representatives. | Class III |
| Failure to maintain adequate housekeeping and maintenance, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. | — |
| Failure to administer medications as ordered by physician, including incomplete insulin administration documentation and improper administration of eye drops without required time intervals. | Class I |
Report Facts
Census: 7
Deficiencies cited: 4
Blanks in medication administration record: 14
Blanks in medication administration record: 34
Residents affected: 7
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW HFSII Surveyor | Named as surveyor conducting the inspection |
| Kathy Beauchamp | HFNSII Surveyor | Named as surveyor conducting the inspection |
Inspection Report
Original Licensing
Census: 3
Deficiencies: 4
Jul 15, 2009
Visit Reason
The inspection was conducted as an initial licensure survey for Madison Park Healthcare to assess compliance with state regulations for employee training, admission and discharge procedures, and facility maintenance.
Findings
The survey found deficiencies including failure to provide adequate employee orientation and training prior to unsupervised work, incomplete resident admission agreements lacking required information, and inadequate housekeeping and maintenance in the facility.
Severity Breakdown
Class II: 1
Class III: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide and maintain a record of training to new employees prior to scheduling them to work unsupervised and within the first fifteen days of employment. | Class II |
| Failure to develop an admission contract including all required information such as resident population served, health and nursing care services, contract price, discharge criteria, complaint procedures, medication management, residents' funds management, and liability insurance coverage. | Class III |
| Failure to provide current residents with a new or updated contract that includes required provisions within ninety days of the effective date of the rule. | Class III |
| Failure to ensure adequate housekeeping and maintenance required to carry out services, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. | — |
Report Facts
Census: 3
Sample Size: 3
Residents affected: 4
Completion Date: Aug 5, 2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW HFSII | Surveyor conducting the inspection |
| Kathy Beauchamp | HFNSII | Surveyor conducting the inspection |
Inspection Report
Original Licensing
Census: 3
Deficiencies: 0
Jul 15, 2009
Visit Reason
Initial licensure survey conducted to assess the facility's compliance with regulatory requirements for licensing.
Findings
The report documents the initial licensure survey with a census of 3 residents. A follow-up survey was conducted later to verify correction of deficiencies, which were corrected.
Report Facts
Census: 3
Census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW HFSII | Surveyor for initial licensure and follow-up surveys |
| Kathy Beauchamp | HFNSII | Surveyor for initial licensure and follow-up surveys |
Inspection Report
Original Licensing
Deficiencies: 3
Jun 8, 2009
Visit Reason
The inspection was conducted as an initial licensure survey to evaluate the environment and compliance with physical facility requirements.
Findings
The survey found deficiencies related to equipment maintenance, including an uncovered compressor with condensation dripping onto electrical components, and issues with kitchen and food preparation areas not being inspected or approved by the local health department. Additional findings included the need for an elevator device to restrict resident access to certain floors.
Severity Breakdown
Class III: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| The compressor located in the basement was not covered/protected to prevent contact with moving parts and had condensation dripping onto electrical components. | Class III |
| The kitchen and food preparation areas had not been inspected or approved by the local health department; a certificate and permit to operate were required prior to operation. | Class III |
| The elevator lacked a device to deny residents access to the fourth floor and basement, which are off limits unless accompanied by staff. | Class III |
Report Facts
Census: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Named as surveyor conducting the initial licensure survey |
| Jason Lintner | Surveyor | Named as surveyor conducting the initial licensure survey |
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