Inspection Reports for Madison Center

An unannounced onsite revisit survey was conducted at The Madison from January 27-29 for the annual survey concluding on November 21, 2024. The facility was not in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

The facility failed to ensure a resident had a person-centered comprehensive care plan developed and implemented to meet the resident's medical, physical, mental, and psychosocial needs. Specifically, Resident #259's care plan and kardex did not include contact isolation precautions related to excessive wound drainage.

The visit was conducted as a revisit annual recertification and annual relicensure survey to assess compliance with long term care facility regulations.

The facility was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected as evidenced by accepted plans of correction and credible evidence.

The document is a Statement of Deficiencies and Plan of Correction related to a facility survey conducted to assess compliance with federal, state, and local Emergency Preparedness requirements.

The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements. No deficiencies were cited in this area.

An unannounced annual recertification/licensure survey was conducted at The Madison from 11/18/24 to 11/21/24. The facility was found out of substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

The facility was found to have multiple deficiencies including failure to follow menus during meal service, medication errors, inaccurate care plans, failure to notify physicians of changes, undignified resident pictures, inaccurate Minimum Data Set (MDS) reporting, failure to provide bed hold notices, failure to provide trauma-informed care, and infection control issues such as oxygen tubing on the floor. An immediate jeopardy was identified related to unsafe transport of a resident in a manual wheelchair.

Complaint 33251 was unsubstantiated. Complaint 33470, 34264, and 34587 were substantiated.

The inspection was conducted to assess compliance with fire safety codes, electrical safety standards, and resident rights regulations at the facility.

The facility was found deficient in maintaining smoke and fire barriers with proper fire resistance ratings and ensuring electrical junction boxes had no open punch outs, potentially affecting all residents, staff, and visitors. The facility was found in compliance with Emergency Preparedness requirements.

An unannounced complaint investigation survey was conducted at The Madison on 09/25/23 from 9:30 AM to 4:00 PM.

The facility was found to be in substantial compliance with applicable regulations. Complaint #29146 was unsubstantiated with no related or unrelated deficiencies.

Complaint #29146 was unsubstantiated with no related or unrelated deficiencies.

An unannounced complaint investigation survey was conducted at The Madison from 05/15/23 to 05/16/23.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaint #28374 was unsubstantiated with no related or unrelated deficiencies cited.

Complaint #28374 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced annual recertification and relicensure survey was conducted to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including accuracy of assessments, notice requirements before transfer/discharge, accident hazard supervision, comprehensive care planning, baseline care plans, confidentiality of resident information, bed hold notices, food safety, POST form completion, and COVID-19 notification.

The visit was conducted as an annual recertification and annual relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, The Madison, was found to be in substantial compliance with the applicable federal and state regulations. Plans of correction and credible evidence were accepted in lieu of an onsite revisit.

The inspection was conducted as a routine survey to assess compliance with NFPA standards related to cooking facilities and fire drills.

The facility failed to ensure that cooking equipment was protected in accordance with NFPA 101 and 96, and failed to conduct fire drills at unexpected times under varying conditions as required by NFPA 101. These deficiencies could affect all residents, staff, and visitors.

The inspection was conducted as a complaint investigation survey, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, The Madison, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

The complaint investigation survey concluded on 08/16/2022, and the facility was found to be in substantial compliance with previously cited deficient practices.

An unannounced complaint investigation survey was conducted at The Madison from August 15-16, 2022, based on complaint #27137 which was unsubstantiated but unrelated deficiencies were cited.

The facility was found deficient in ensuring a resident who was deemed inappropriate to self-administer medications had staff supervision during a breathing treatment, and in following menus and recipes for meals served to residents.

Complaint #27137 was unsubstantiated with unrelated deficiencies cited at F554 and F803.

The inspection was conducted as a complaint investigation survey based on two complaints received by the facility.

No deficiencies were cited during the complaint investigation survey. Both complaints were found to be unsubstantiated.

Complaint #26698 and Complaint #26718 were both unsubstantiated.

An unannounced complaint investigation survey was conducted at The Madison on April 4, 2022.

The complaint #26590 was unsubstantiated with no related or unrelated deficiencies cited. The findings are based on observations, clinical record reviews, resident, family, and staff interviews, and other facility documentation.

Complaint #26590 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced complaint investigation survey was conducted at The Madison from March 7-9, 2022.

The facility was in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. Complaint #26517 was unsubstantiated with no related or unrelated deficiencies cited.

Complaint #26517 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced onsite revisit survey was conducted at The Madison from March 7-9, 2022 for the annual survey concluding on December 9, 2021.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

The inspection was conducted as an annual survey to assess compliance with NFPA standards for sprinkler system maintenance and HVAC system requirements, including fire/smoke damper testing and emergency preparedness compliance.

The facility failed to maintain automatic sprinkler and standpipe systems according to NFPA 25 standards, lacking documentation of ten-year testing of sprinkler heads. Additionally, the facility did not have documentation for testing multiple fire/smoke dampers in various locations, violating NFPA 90A requirements. The facility was found to be in compliance with emergency preparedness requirements.

An unannounced off hours, extended annual recertification, annual relicensure, and complaint investigation survey was conducted at The Madison from December 6-9, 2021.

The facility was found deficient in multiple areas including call light accessibility, advance directives completion, freedom from abuse and neglect, transfer and discharge documentation, care planning, infection control, pain management, and food service safety. Several residents were affected by these deficiencies.

Complaint #26035 was substantiated with a related deficiency cited at F684. Complaint #25652 was substantiated with related deficiencies cited at F600, F622, F623, F661, F684, F689, and F880.

The inspection was conducted as an annual survey to assess compliance with federal and state regulations, including fire safety, equipment maintenance, and resident rights.

The facility was found deficient in multiple areas including failure to maintain and test fire alarm and sprinkler systems according to NFPA standards, improper storage in mechanical rooms affecting gas and electrical equipment safety, lack of documentation for HVAC fire/smoke damper testing, failure to maintain electrical equipment testing records, and failure to inspect fire door assemblies annually. These deficiencies could potentially affect all residents, staff, and visitors.

The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 09/13/2021 and 09/19/2021 as required by regulation, which has the potential to cause more than minimal harm to all residents.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency at The Madison on January 7 - 12, 2021.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

Unannounced complaint investigations #23226 and #23217 were conducted at The Madison from 10/06/20 to 10/14/20 to investigate allegations.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable federal and state regulations.

Unannounced complaint investigations #23226 and #23217 were conducted. No citations and no substantiated allegations were found.

The inspection was conducted to review the facility's compliance with infection control regulations and CMS/CDC recommended practices to prepare for COVID-19.

The facility was found to be in substantial compliance with 42 CFR 483.80 infection control regulations and CMS/CDC recommended practices for COVID-19, with credible evidence supporting correction of previously cited deficiencies.

A COVID-19 Focused Infection Control Survey was conducted by the state survey agency on July 16-17, 2020 to assess compliance with infection control regulations and CMS/CDC recommended practices for COVID-19 preparation.

The facility was found out of compliance with infection control regulations due to failure of an employee (E#1) to properly dispose of contaminated gloves and perform hand hygiene after glove removal on the Admission Quarantine Unit (AQU). The Director of Nursing immediately reeducated the employee and implemented audits and reeducation for all staff to ensure compliance.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, The Madison, was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The document is a Statement of Deficiencies and Plan of Correction related to a facility survey to assess compliance with Federal, State, and local Emergency Preparedness requirements.

Based on review of facility documentation and staff interview, the facility was found to be without waivers and in compliance with all applicable Emergency Preparedness requirements.

The inspection was a routine survey to assess compliance with various regulatory requirements including emergency lighting, HVAC fire/smoke dampers, electrical equipment safety, and power strip usage.

The facility was found deficient in multiple areas including failure to test emergency lighting systems, fire/smoke dampers, and patient-care electrical equipment according to NFPA standards. Additionally, power strips were improperly used in a patient care vicinity. The facility acknowledged these findings and submitted plans of correction.

An unannounced annual re-certification and annual re-licensure survey was conducted from 10/21/19 through 10/24/19 to assess compliance with federal and state regulations.

The facility was found deficient in multiple areas including failure to provide reasonable accommodations for residents to operate overhead lights, failure to inform residents about advance directives, unsafe and unsanitary environment conditions, failure to report allegations of missing property, incomplete and inaccurate care plans, failure to provide proper pressure ulcer care, inadequate catheter care, unlabeled enteral feeding equipment, improper hand hygiene during tracheostomy care, incomplete medical records, infection control deficiencies including improper isolation precautions, and lack of soap in the medication storage room.

The inspection was conducted as a complaint investigation survey based on complaint references #23060 and #22952, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, The Madison, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with no new deficient practices cited during this complaint investigation.

Complaint references #23060 and #22952 were investigated. The facility was found in substantial compliance with previously cited deficient practices, and no new deficiencies were noted.

Unannounced complaint surveys #23060 & 22952 were conducted at The Madison from 08/19/19 through 08/21/19 based on observations, clinical record reviews, resident/family/staff interviews, and facility documentation review.

The facility failed to ensure residents were free from neglect related to wound care, with treatment omissions and discrepancies in wound care orders and administration. Additionally, care plans lacked documentation for smoking status and safe smoking interventions. The facility also failed to ensure proper positioning of residents during feeding and failed to maintain call light buttons within residents' reach. A reportable incident involved maggots found in a resident's wound.

The complaint involved allegations of neglect related to wound care, including a report of maggots found in a resident's wound on 07/19/19. The facility reported timely to state agencies. The five-day follow-up did not substantiate or refute the allegation but stated the facility was providing wound care as prescribed by a physician.

An unannounced complaint investigation was conducted at The Madison from 06/17/19 through 06/18/19.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaint #22660 and Complaint #22411 were both unsubstantiated with no related or unrelated deficiencies cited.

Complaint #22660 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #22411 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced complaint investigation was conducted at The Madison from 01/14/19 to 01/16/19 to investigate allegations.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable federal and state regulations.

Complaint #21273 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #21347 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, The Madison, was found to be in substantial compliance with the applicable federal and state regulations based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

An unannounced annual re-certification and annual re-licensure survey was conducted at The Madison from October 1, 2018 through October 11, 2018.

The facility was found deficient in multiple areas including failure to ensure residents could participate in outside activities, failure to notify physicians of medication administration issues, incomplete comprehensive care plans, failure to follow physician orders for medications and lab work, improper use of psychotropic medications, unsecured medication carts, unsanitary food storage, inadequate infection control practices during wound care, and incomplete pneumococcal vaccination history documentation.

Routine inspection conducted to assess compliance with National Fire Protection Association (NFPA) standards and other regulatory requirements related to fire safety, electrical systems, emergency preparedness, and resident rights.

The facility was found deficient in multiple areas including emergency lighting testing, hazardous area door closures, cooking facility maintenance, sprinkler system maintenance, fire extinguisher inspections, smoke barrier door compliance, fire drill timing, electrical breaker box accessibility, electrical receptacle testing, generator maintenance, and electrical equipment testing. Plans of correction were submitted for all deficiencies with reeducation and auditing procedures implemented.

An unannounced complaint survey was conducted at The Madison on 02/05/18 to 02/06/18 to investigate complaints #19536, #19052, #19110, and #18984.

The complaints were unsubstantiated and no related or unrelated deficiencies were cited. The facility was found to be in substantial compliance with applicable federal and state regulations.

Complaints #19536, #19052, #19110, and #18984 were investigated and found to be unsubstantiated with no deficiencies cited.

An unannounced revisit was conducted at The Madison on January 9, 2018 through January 10, 2018 for the Quality Indicator Survey concluding on October 10, 2017.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

Unannounced annual Quality Indicator Survey, State Licensure Survey and Complaint Investigation Surveys were conducted from 2017-09-18 through 2017-10-10.

The facility was cited for multiple deficiencies including failure to notify physicians of changes in condition, failure to protect residents from abuse, inadequate pain management, failure to update care plans, inadequate housekeeping and maintenance, improper food handling, infection control breaches, insufficient nurse staffing and training, and failure to maintain a quality assessment and assurance program.

Complaint Investigations #18725, #18608, #18528, and #18847 were substantiated with related deficiencies involving abuse, neglect, and failure to notify physicians.

The inspection was conducted to evaluate compliance with NFPA 101 standards related to means of egress illumination, fire drills, electrical systems maintenance and testing, and electrical equipment safety in the facility.

The facility failed to ensure proper illumination of means of egress lighting, failed to conduct fire drills on all shifts quarterly, failed to maintain and test electrical receptacles at patient bed locations, and failed to complete electrical safety testing on patient-care related equipment. Corrective actions and re-education plans were outlined for each deficiency.

Complaint survey conducted from 2017-09-18 to 2017-10-10 with an extended survey from 2017-10-02 to 2017-10-05. The survey was triggered by multiple substantiated complaints involving abuse, neglect, and failure to follow care plans.

The facility was cited for multiple deficiencies including failure to notify physicians and family of changes in condition, failure to protect residents from verbal and physical abuse, failure to investigate abuse allegations thoroughly, failure to provide adequate pain management, failure to update care plans, failure to provide adequate tracheostomy care, failure to ensure sufficient nursing staff and competency, failure to maintain accurate clinical records, failure to provide adequate tube feeding, failure to post accurate staffing information, and failure to maintain infection control standards.

Complaint survey triggered by multiple substantiated complaints including abuse allegations (verbal and physical), failure to notify physicians and family of changes in condition, failure to provide adequate care and pain management, and failure to maintain accurate records.

An unannounced complaint investigation was conducted at The Madison from February 6, 2017 to February 8, 2017 for Complaint Reference #17150.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

Complaint Reference #17150 was investigated and found to be unsubstantiated with no deficiencies identified.

The document is a plan of correction submitted by the facility in response to previously cited deficiencies during Quality Indicator and Licensure Surveys concluding on 08/11/16.

The facility, The Madison, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. The plan of correction and credible evidence were accepted in lieu of an onsite revisit, indicating correction of previously cited deficient practices.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at The Madison from August 8, 2016 through August 11, 2016.

The facility was found deficient in multiple areas including failure to maintain residents' dignity during dining, improper medication management including unnecessary drug use and lack of monitoring, unsanitary food preparation and storage conditions, failure to act on pharmacy recommendations, and inadequate infection control practices including failure to enforce isolation precautions and improper hand hygiene during medication administration.

The inspection was a routine survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements for the facility.

The facility was found deficient in multiple areas including failure to properly fireproof smoke barrier penetrations, inadequate fire drill timing and documentation, incomplete fire alarm system maintenance, missing monthly fire extinguisher checks, lack of timely dietary exhaust hood inspections, and insufficient generator inspection and documentation.

An unannounced complaint survey was conducted at The Madison on 10/28/15 to 10/29/15 in response to Complaint #14733.

The complaint was unsubstantiated with no deficiencies cited. The survey included observation and review of 50 resident beds and three residents.

Complaint #14733 was unsubstantiated with no deficiencies cited.

An unannounced complaint investigation was conducted from September 8, 2015 to September 10, 2015 at The Madison for Complaint Reference #14115.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified.

The document is a plan of correction related to a prior Quality Indicator and Licensure Survey for a long term care facility, submitted in lieu of an onsite revisit.

The facility, The Madison, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence accepted instead of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 06/25/15.

The inspection was a routine survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements at the facility.

The facility was found to have multiple deficiencies including failure to maintain corridor doors to close and latch properly, a delayed-egress door failing to release as required, fire drills not conducted at unexpected times on night shifts, and sprinkler pipes loaded with wires violating NFPA standards.

Unannounced Quality Indicator and State Licensure Surveys were conducted to assess compliance with federal and state regulations through observations, record reviews, interviews, and facility documentation.

The facility was found deficient in multiple areas including failure to update care plans after resident falls, inadequate participation of hospice staff in care planning, unsecured hazardous rooms, dietary staff not wearing proper hair restraints, improper infection control practices during catheter care, and inaccuracies in clinical records related to medication orders.

The document is a plan of correction related to a Quality Indicator and Licensure Survey, accepted in lieu of an onsite revisit for the facility's compliance review.

The facility, The Madison, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.

Unannounced Quality Indicator and Licensure surveys were conducted at The Madison from March 04, 2014 through March 06, 2014 to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including housekeeping and maintenance with 17 rooms in disrepair, inaccurate comprehensive resident assessments, failure to provide required transfer/discharge notice information, incomplete employee background checks, unlocked soiled utility closet containing hazardous materials, and improper garbage disposal with overflowing dumpsters.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code Standards, including fire drills, medical gas storage, and generator maintenance.

The facility failed to conduct required quarterly fire drills on the afternoon shift for the second quarter of 2013, failed to secure free standing oxygen cylinders and segregate empty from full cylinders, and failed to maintain battery-powered emergency lighting in the generator transfer switch room.

The inspection was conducted in response to two complaint references, 12183 / 7259 and 12211 / 7249.

Both complaints were found to be unsubstantiated with no citations issued.

Complaint Reference 12183 / 7259 and Complaint Reference 12211 / 7249 were both unsubstantiated with no citations.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of the facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as part of Quality Indicator and Licensure Surveys from 07/30/12 to 08/07/12.

The facility was found deficient in multiple areas including failure to notify residents or responsible parties of changes in condition or roommate changes, incomplete and inaccurate resident assessments, failure to maintain sanitary food handling practices, inadequate infection control practices including improper handwashing by staff, and incomplete documentation of a resident's hypoglycemic episode.

The inspection was conducted to evaluate the facility's compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the maintenance and testing of the fire alarm system and its components.

The facility failed to maintain the fire alarm system in accordance with NFPA 72, as it did not ensure annual testing of all electromechanical releasing devices. Documentation of such testing was missing despite fire alarm testing being completed and documented by an external company.

The inspection was conducted as a complaint investigation based on two complaint references: State #12047 / ACTS #6992 and State #12067 / ACTS #7030.

Both complaints were found to be unsubstantiated with no citations issued during the investigation.

Complaint Reference ID: State #12047 / ACTS #6992 - Unsubstantiated complaint record with no citations; Complaint Reference ID: State #12067 / ACTS #7030 - Unsubstantiated complaint record with no citations.

The inspection was conducted in response to complaint reference #10347.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #10347 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted in response to complaint reference #10236.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #10236 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted to evaluate the facility's compliance with regulatory requirements, specifically focusing on the development and implementation of comprehensive care plans for residents.

The facility failed to develop an interdisciplinary care plan for one resident with dysphagia who was at high risk of altered nutrition and receiving rehabilitative therapy services. Despite documented therapy interventions and weight loss, the resident's care plan did not include specific interventions to reduce meal-time distractions and promote nutritional intake as required by facility policy.

The inspection was conducted following a complaint regarding failure to provide proper written notice of transfer or discharge and failure to ensure a safe and orderly discharge of Resident #57 to a legally unlicensed care home.

The facility failed to provide a written notice of transfer or discharge to Resident #57's legal representative at least 30 days prior to discharge, failed to ensure a safe and orderly discharge, and failed to communicate important medical and care information to the receiving facility. Additionally, the facility failed to accurately assess and address Resident #3's mood and behavioral symptoms, and failed to implement recommended interventions to maintain nutritional status.

Complaint investigation focused on Resident #57's discharge process and Resident #3's care planning and assessment accuracy.

The inspection was conducted as a substantiated complaint investigation concurrently with the facility's annual Federal Medicare/Medicaid resurvey and State licensure inspection.

The facility was found deficient in multiple areas including failure to provide required notice of Medicare non-coverage, failure to maintain resident privacy during medical examinations, inaccurate resident assessments, failure to develop and revise individualized care plans, medication administration errors, failure to comply with PASRR requirements, failure to prevent unnecessary catheterization, and failure to prevent accidents and properly investigate falls.

Complaint reference #10159. Substantiated complaint record with deficiencies cited. The complaint investigation was conducted concurrently with the facility's annual Federal Medicare/Medicaid resurvey and State licensure inspection.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

The inspection was conducted as a complaint investigation based on complaint reference #10142, which was substantiated with deficiencies cited.

The facility failed to post the correct mailing address for the State survey and certification agency and did not provide clear instructions on filing complaints. The facility also failed to notify legal representatives immediately following incidents involving residents, affecting four residents. Additionally, the facility failed to develop a comprehensive care plan for a resident with Lewy body dementia, lacking individualized interventions for fall risk, behavioral issues, and nutritional needs. The resident fell from her wheelchair resulting in injury. The facility did not provide adequate supervision or assistive devices to prevent this accident.

Complaint reference #10142 was substantiated with deficiencies cited related to notification failures, care planning, and posting of complaint information.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of the facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as a complaint investigation related to concerns about the facility's monitoring and treatment of residents, specifically regarding bowel elimination and fluid volume deficits.

The facility failed to adequately monitor residents for acute changes related to constipation and fluid volume deficit, with discrepancies in bowel movement documentation for residents #14 and #37, and omissions in fluid intake/output records for resident #21. Additionally, the facility failed to secure a treatment cart containing hazardous items, posing a risk to residents.

Complaint reference #10008 was substantiated with deficiencies cited related to inadequate monitoring and documentation of residents' bowel movements and fluid intake/output.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for a healthcare facility.

The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101, Life Safety Code; 2000 Existing Edition.

The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition based on the review.

The inspection was conducted concurrently with the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.

The facility was found to have multiple deficiencies including unauthorized disclosure of residents' personal funds information, failure to maintain resident dignity during feeding, incomplete care plans for residents, failure to provide necessary care to maintain highest practicable well-being including medication monitoring and side rail use, and failure to maintain sanitary food storage conditions with improper milk temperatures.

Complaint reference #9246 was unsubstantiated with no related deficiencies cited. The complaint investigation was conducted concurrently with the annual inspection.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically focusing on the fire alarm system's installation, testing, and maintenance.

The facility's fire alarm system inspection report was found incomplete, lacking confirmation of the existence and functional status of magnetic locking delayed egress devices on designated exit doors. Additionally, the testing of sprinkler flows and sprinkler tampers was inadequately documented, and the inspection report did not include all required information per NFPA standards.

The inspection was conducted as a comprehensive annual survey of the nursing facility to assess compliance with federal regulations and standards.

The facility was found deficient in multiple areas including failure to check new employees against the State Nurse Aide Registry, failure to maintain resident dignity, incomplete care plans, improper seating during meals, improper food temperature control, inadequate infection control practices, and incomplete clinical records for a resident.

The inspection was conducted as a complaint investigation related to complaint reference #2-7283.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-7283 was unsubstantiated with no deficiencies cited.

Paper revisit to review the facility's plan of correction and compliance with previously cited deficiencies.

The document contains a statement of deficiencies related to resident rights and notification requirements, with a focus on the facility's obligation to inform residents of their rights and services. No new inspection findings are detailed beyond the plan of correction context.

The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101, Life Safety Code; 2000 Existing Edition.

The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition based on the review conducted.

The inspection was conducted to assess compliance with federal regulations regarding resident rights, financial security, pre-admission screening, and other regulatory requirements for the nursing facility.

The facility was found deficient in ensuring that residents' rights were exercised by legally authorized representatives, maintaining adequate surety bond coverage for residents' funds, and completing pre-admission screening and resident review (PASARR) prior to admission for some residents.

The inspection was conducted as a complaint investigation referenced as #2-7088.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-7088 was unsubstantiated with no deficiencies cited.

The visit was a paper revisit to follow up on previous deficiencies.

The document contains a statement of deficiencies related to resident rights and notification requirements, but no specific findings or deficiencies are detailed in this excerpt.

The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101, Life Safety Code; 2000 Existing Edition.

The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition based on the review.

The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident rights, pre-admission screening, quality of care, sanitary conditions, laboratory services, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to properly document the nature of residents' incapacity, incomplete pre-admission screening reassessments, inadequate pain management and reassessment, failure to assess and treat urinary incontinence and urinary tract infections timely, and unsanitary food preparation conditions. The facility also failed to ensure timely laboratory specimen pickup.

This document is a plan of correction related to a paper revisit survey conducted at the facility.

The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand.

Routine inspection of the nursing facility to assess compliance with federal regulations including resident rights, physical restraints, staff treatment, care plans, medication use, meal frequency, sanitary conditions, dental services, infection control, and employee screening.

The facility was found deficient in multiple areas including failure to assess and implement least restrictive restraints, inadequate staff screening for criminal background and physical exams, improper delegation of nursing tasks, failure to justify use of psychoactive drugs, failure to provide night snacks to all residents, improper food labeling, failure to provide needed dental care, and failure to notify employees of the Central Abuse Registry as required by state law.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including fire drill procedures, sprinkler system maintenance, means of egress, and medical gas storage and administration.

The facility failed to ensure all staff were familiar with fire drill procedures, maintain sprinkler systems free of corrosion and paint, keep means of egress clear of obstructions, and properly store oxygen cylinders in secured cabinets with appropriate signage.

The inspection was conducted as a complaint investigation referenced as #2-4312, which was unsubstantiated with no deficiencies cited in that regard.

The facility was found deficient in providing appropriate care to a resident with limited range of motion by not applying physician-ordered devices. Additionally, the facility failed to offer bedtime snacks to all residents and did not store food under sanitary conditions in the kitchen.

Complaint reference #2-4312 was unsubstantiated with no deficiencies cited related to the complaint.

The survey was conducted to assess the facility's compliance with the Life Safety Code NFPA 101 - 2000 Existing.

Based on observation, performance testing, and review of facility documentation during the survey from 09/14/04 to 09/15/04, the facility was determined to be in compliance with the Life Safety Code NFPA 101 - 2000 Existing.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code; 2000 Existing Edition.

The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

The inspection was conducted as a complaint investigation referenced as #2-3211, to evaluate allegations related to staff treatment of residents and other regulatory compliance issues.

The facility was found to have multiple deficiencies including failure to verify nursing licenses and nurse aide registry status from other states, delayed reporting of an injury of unknown origin, inadequate dining assistance for residents, unsanitary food preparation practices, and incomplete clinical records regarding statements of incapacity for residents.

Complaint reference #2-3211 was unsubstantiated with no deficiencies cited related to the complaint itself, but other deficiencies were identified during the investigation.

The inspection was conducted in response to a complaint, referenced as #2-3055.

The document contains a statement of deficiencies related to resident rights and notification requirements, specifically citing a deficiency under F 156 regarding the facility's obligation to inform residents of their rights and services.

Complaint reference number #2-3055 is noted; no substantiation status is provided.

The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101, Life Safety Code; 1985 New Edition.

The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 1985 New Edition based on the review.

The inspection was conducted to assess compliance with federal regulations regarding resident rights, quality of care, and accident hazard prevention in the facility.

The facility was found deficient in informing residents of their rights and services, providing necessary care to a resident with infections, and ensuring a safe environment free of accident hazards for a resident with seizures. Specific deficiencies included lack of monitoring and documentation of infections for Resident #27 and inadequate interventions related to side rails and seizure risks for Resident #3.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101; Life Safety Code, 1985 New Edition.

Based on review of facility documentation, staff interview, performance testing, and observation, the facility was determined to be in compliance with the Life Safety Code.

The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, physical restraints, resident assessments, quality of care, and clinical record maintenance.

The facility was found deficient in multiple areas including improper use of physical restraints on a resident without proper evaluation or alternatives, failure to develop comprehensive care plans for residents with specific needs, inadequate monitoring and care for residents with tracheostomies, failure to provide ambulation assistance as ordered, and incomplete clinical records with missing follow-up assessments.

The inspection was conducted to assess compliance with the Life Safety Code based on facility documentation review, staff interview, performance testing, and observation.

The facility was found to be in compliance with the provisions of NFPA 101; Life Safety Code, 1985 New Edition.

A recertification survey was completed on March 26-29, 2001 to assess compliance with OBRA regulations.

The facility was found to be in compliance with all OBRA regulations during the recertification survey.

The inspection was conducted in response to complaint ID 2-0199 regarding allegations of staff mistreatment and abuse of residents.

The facility failed to report two allegations of abuse immediately to the appropriate state agencies as required by state law. Additionally, one nurse aide was found to be working without valid state certification, as the facility did not verify certification prior to employment.

Complaint ID 2-0199 involved allegations that a CNA removed food from a resident's mouth roughly and that a staff member verbally abused a resident by forcing feeding despite a physician's order. Both incidents were not reported to Adult Protective Services or the Nurse Aide Registry as required.

The inspection was conducted as a complaint investigation (Complaint No. 2-0102) to assess the facility's compliance with resident rights, quality of life, and dietary service standards.

The facility failed to maintain a dignified dining environment for seven residents requiring total feeding, failed to provide fresh cold water to all 52 residents, did not offer substitute foods when residents disliked meals, served food at improper temperatures, and served food under unsanitary conditions on one hallway.

Complaint No. 2-0102 triggered the investigation. The complaint was substantiated based on observations and staff/resident interviews revealing multiple quality of life and dietary service deficiencies.

The inspection was conducted based on a review of facility documentation, staff interview, and observations to determine compliance with the provisions of 483.70 Physical Environment.

The facility was found to be in compliance with the provisions of 483.70 Physical Environment.

The inspection was conducted to review the facility's compliance with the provisions of the Fire Safety Survey Report Short Form, as applicable to NFPA 101:12, Life Safety Code, 1985 New.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the applicable Life Safety Code provisions.

The inspection was conducted as an annual survey to determine compliance with State and Federal regulations.

Based on the survey conducted from June 14-16, 2000, The Madison was determined to be in compliance with all State and Federal regulations.

The inspection was conducted as part of the annual survey to assess compliance with federal regulations regarding resident rights and quality of care.

The facility failed to inform residents of their rights as required and did not provide necessary treatment for a stage III pressure sore on a resident's right ankle, which was missed during weekly skin audits.