Inspection Reports for
Madrid Home for the Aging
613 West North Street, Madrid, IA, 501561059
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% worse than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
81% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 22, 2025
Visit Reason
A complaint investigation was conducted for complaints #2587445-C, #2607051-C, #2608059-C, #2603083-C, #2617243-C, #2609330-C, #2624340-C, #2625294-C and #2625420-C from September 22, 2025 to September 25, 2025.
Complaint Details
Investigation of multiple complaints as listed; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Aug 5, 2025
Visit Reason
The inspection was conducted as a result of investigations into complaints #129023-C, #128744-C, #129021-C, and #128291-C from July 29, 2025 to August 5, 2025.
Complaint Details
The deficiencies resulted from investigation of complaints #129023-C, #128744-C, #129021-C, and #128291-C. The report documents medication errors and narcotic management issues substantiated by clinical record review, staff interviews, and facility policy review.
Findings
The facility failed to meet professional standards of quality related to medication administration, resulting in medication errors for 2 of 2 residents reviewed. Deficiencies included missing fentanyl patches, inaccurate narcotic counts, and failure to ensure proper narcotic storage and disposal procedures.
Deficiencies (1)
Failure to assure residents received medications per physician orders resulting in medication errors for 2 of 2 residents reviewed.
Report Facts
Resident census: 52
Number of complaints investigated: 4
MDS assessment date: May 13, 2025
MDS assessment date: Jul 27, 2025
Incident report date: Apr 2, 2025
Incident report date: Apr 3, 2025
Incident report date: May 9, 2025
Medication administration frequency: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 18, 2025
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, leading to certification effective April 18, 2025.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Mar 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate assessment and intervention for a resident's insulin and blood sugar management.
Complaint Details
The complaint investigation found substantiated failure to provide adequate assessment and intervention for insulin and blood sugar management for Resident #19, including lack of documentation and failure to follow facility policy and professional standards.
Findings
The facility failed to properly assess and intervene for Resident #19's low blood sugar event, including lack of documentation and failure to recheck the resident after a low blood sugar reading of 51 mg/dl. Staff interviews confirmed the nurse did not follow facility policy or professional standards for monitoring and documenting hypoglycemia.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences for Resident #19's diabetes management. The nurse did not recheck or document a low blood sugar reading of 51 mg/dl and failed to monitor the resident as required by facility policy.
Report Facts
Resident census: 52
Low blood sugar reading: 51
Scheduled blood sugar reading: 191
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Registered Nurse (RN) | Named in failure to document and recheck low blood sugar for Resident #19 |
| Staff H | Licensed Practical Nurse (LPN) | Named in reporting lack of communication and documentation regarding Resident #19's low blood sugar |
| Director of Nursing | Director of Nursing (DON) | Provided statements on facility expectations for blood sugar monitoring and documentation |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 5
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #125815-C, #126042-C, and #126124-C from March 17 to March 20, 2025.
Complaint Details
Complaints #126042-C and #126124-C were substantiated during the investigation.
Findings
The facility was found to have multiple deficiencies including failure to provide proper notice to residents about discontinuing Medicare Part A services, failure to meet professional standards in medication administration, inadequate assessment and care for residents with blood sugar issues, failure to properly manage psychotropic medications, and food safety violations related to storage and temperature monitoring.
Deficiencies (5)
Failed to provide notice to residents of discontinued Medicare Part A services and the right to appeal.
Failed to obtain physician and pharmacy orders for correct medication administration for 1 of 7 residents reviewed.
Failed to provide adequate assessment and intervention for resident with insulin and blood sugar issues.
Failed to ensure residents on psychotropic medications received appropriate gradual dosage reductions and documentation for PRN orders beyond 14 days.
Failed to ensure food was stored, prepared, and delivered in a manner to prevent foodborne illnesses; issues with undated dish machine test strips, improper storage of chemical jug, and incomplete temperature logs.
Report Facts
Census: 52
Deficiencies cited: 5
Dates of medication orders and reviews: Various dates including 11/7/24, 11/29/24, 3/13/25, 3/17/25, 1/6/25, 1/18/25, 2/10/25, 2/17/25, 3/31/25
Inspection Report
Routine
Census: 52
Deficiencies: 5
Date: Mar 20, 2025
Visit Reason
Routine inspection to assess compliance with regulatory standards related to resident care, medication administration, psychotropic medication use, food safety, and notification requirements for Medicare Part A services.
Findings
The facility failed to provide required Medicare Part A discontinuation notices to residents, did not obtain proper physician and pharmacy orders for medication administration routes, failed to adequately assess and intervene for low blood sugar in a diabetic resident, did not attempt gradual dose reductions for psychotropic medications or limit PRN use as required, and failed to ensure food safety protocols including proper storage, temperature logging, and hand hygiene.
Deficiencies (5)
F582: The facility failed to provide notice to residents of discontinued Medicare Part A services and the right to appeal for two residents.
F658: The facility failed to obtain a physician and pharmacy order for the correct route of medication administration for one resident.
F684: The facility failed to provide adequate assessment and intervention for low blood sugar in one resident with diabetes.
F758: The facility failed to attempt gradual dose reductions for psychotropic medication and failed to limit PRN psychotropic medication use to 14 days without physician review for two residents.
F812: The facility failed to ensure food was stored, prepared, and delivered in a manner to prevent foodborne illness, including lack of temperature logs, improper chemical storage, and poor hand hygiene.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 52
PRN medication days: 22
PRN medication days: 15
PRN medication days: 3
Medication dose: 100
Medication dose: 0.5
Blood sugar level: 51
Blood sugar level: 191
Dish machine test strips: 31
Dish machine test strips failing temperature: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medical Assistant | Administered medication by mouth instead of G-Tube for Resident #7 |
| Staff F | Licensed Practical Nurse | Acknowledged lack of signed physician order for medication route change for Resident #7 |
| Staff G | Registered Nurse | Failed to adequately monitor and document low blood sugar for Resident #19 |
| Staff H | Licensed Practical Nurse | Reported lack of communication and documentation regarding Resident #19's low blood sugar |
| Director of Nursing | Director of Nursing | Confirmed deficiencies in notification, medication orders, blood sugar monitoring, and psychotropic medication management |
| Staff A | Dietary Aide | Observed holding drinkware improperly and poor hand hygiene during meal prep |
| Staff B | Dietary Aide | Observed holding drinkware improperly and poor hand hygiene during meal service |
| Staff C | Cook | Observed poor hand hygiene after touching trash can |
| Staff D | Dietary Staff | Acknowledged issues with dish machine temperature test strip recording |
| Certified Dietary Manager | Certified Dietary Manager | Acknowledged lack of temperature logs and improper food safety practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 23, 2024
Visit Reason
The visit was conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on a credible allegation of compliance and plan of correction.
Findings
The Madrid Home was found to be in substantial compliance effective June 23, 2024, based on the department's acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from June 3, 2024 to June 6, 2024.
Findings
The facility failed to meet requirements related to coordination of PASARR assessments, development and implementation of comprehensive person-centered care plans, and meeting professional standards for services provided, including proper physician orders for indwelling catheters. Multiple residents' care plans lacked focus areas, goals, and interventions to address specific diagnoses and risks such as elopement and mental health conditions.
Deficiencies (3)
Failure to coordinate PASARR assessments and refer residents with newly evident or possible serious mental disorders to the appropriate state-designated authority.
Failure to develop and implement comprehensive person-centered care plans for residents, including measurable objectives and timeframes.
Failure to meet professional standards of quality by not obtaining physician orders for indwelling catheters for residents.
Report Facts
Census: 52
Residents reviewed for care plans: 16
Residents with indwelling catheter orders missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan updates and acknowledged deficiencies in care plans and resident elopement attempts. | |
| Assistant Director of Nursing | Interviewed regarding therapy recommendations and expectations to follow therapy recommendations. | |
| Staff A Certified Nurse Aide | Certified Nurse Aide | Interviewed and stated unawareness of right wrist brace for Resident #39. |
| Staff B | Certified Nurse Aide | Interviewed and stated Resident #39 wears a right ankle brace but no wrist brace. |
Inspection Report
Routine
Census: 52
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pre-admission screening, care planning, and professional standards of quality in a nursing home.
Findings
The facility failed to refer a resident for a required Level II PASARR evaluation, did not develop and implement comprehensive care plans for multiple residents, and failed to obtain physician orders for indwelling catheters for two residents. The facility reported a census of 52 residents.
Deficiencies (3)
Coordinate assessments with the pre-admission screening and resident review program; the facility failed to refer a resident for a Level II PASARR evaluation after a new mental disorder diagnosis.
Develop and implement a complete care plan that meets all the resident's needs; the facility failed to develop comprehensive care plans for 4 of 16 residents reviewed, lacking focus areas, goals, and interventions.
Ensure services meet professional standards; the facility failed to obtain physician orders for indwelling catheters for 2 residents, despite their use and documentation of catheter care.
Report Facts
Residents census: 52
Residents reviewed for care plans: 16
Residents affected by care plan deficiency: 4
Residents affected by PASARR referral deficiency: 1
Residents affected by catheter order deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed resident's new diagnosis and care plan expectations; acknowledged care plan deficiencies and catheter order issues |
| Assistant Director of Nursing | Assistant Director of Nursing | Stated expectation to follow therapy recommendations for residents |
| Staff A | Certified Nurse Aide | Unaware of wrist brace for Resident #39 |
| Staff B | Certified Nurse Aide | Reported Resident #39 wears ankle brace but no wrist brace |
| Staff C | Certified Nurse Aide | Reported Resident #39 wears ankle brace but no wrist brace |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
A complaint investigation for complaint #113551-C was conducted from April 23, 2024 to April 25, 2024.
Complaint Details
Complaint #113551-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 8, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on May 8, 2023.
Findings
The facility was certified in compliance effective April 27, 2023, based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 6
Date: Mar 27, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify residents of bed hold policies, incomplete care plans after new diagnoses, failure to follow physician orders, medication errors, failure to offer influenza vaccination, and improper COVID-19 vaccine consent.
Complaint Details
The investigation was complaint-driven, focusing on issues such as failure to notify residents of bed hold policies, incomplete care plans, failure to follow physician orders, medication errors, failure to offer influenza vaccination, and improper COVID-19 vaccine consent. The facility reported a census of 41 residents.
Findings
The facility failed to notify a resident or representative of the bed hold policy during hospital transfer, update care plans to reflect new diagnoses and medications, follow physician orders for lab work, prevent significant medication errors including duplicate medication cards and missing doses, offer influenza vaccination documentation, and obtain proper consent for COVID-19 bivalent booster vaccination.
Deficiencies (6)
F 0625: The facility failed to notify a resident or representative in writing of the bed hold policy at the time of hospital transfer for one resident.
F 0657: The facility failed to update care plans to reflect new diagnoses and medications for two residents.
F 0658: The facility failed to follow a physician's order for lab work for one resident.
F 0760: The facility failed to prevent significant medication errors for four residents, including duplicate medication cards and missing doses.
F 0883: The facility failed to offer influenza vaccination documentation for one resident.
F 0887: The facility failed to ensure proper consent was obtained before administering a COVID-19 bivalent booster vaccine for one resident.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Regional Director of Quality and Clinical Services | Confirmed care plan deficiencies, medication errors, and COVID-19 vaccine consent error |
| Staff B | Certified Medication Aide (CMA) | Reported medication variance for Resident #32 |
| Staff C | Certified Medication Aide (CMA) | Administered medications on 3/9/23 and reported medication card handling |
| Staff H | Certified Medication Aide (CMA) | Reported medication card handling and medication disposal |
| Administrator | Verified deficiencies and investigation details | |
| Staff D | Reported pharmacy medication card handling and medication cart management | |
| Staff I | Licensed Practical Nurse (LPN) | Notified about medication variance and completed resident assessment |
| Staff F | Regional Director of Quality and Clinical Services | Obtained verbal consents and involved in COVID-19 vaccine consent error |
| Interim Director of Nursing (IDON) | Signed consent forms and notified physician and family regarding COVID-19 vaccine error |
Inspection Report
Routine
Census: 41
Deficiencies: 7
Date: Mar 27, 2023
Visit Reason
Routine inspection of Madrid Home for the Aged to assess compliance with regulatory standards including resident care, medication management, food safety, and immunization policies.
Findings
The facility had multiple deficiencies including failure to notify residents or representatives about bed hold policies, incomplete care plans reflecting new diagnoses and medications, failure to follow physician orders, significant medication errors, improper food storage, and failure to properly offer and document influenza and COVID-19 vaccinations.
Deficiencies (7)
F 0625: The facility failed to notify Resident #36 or their representative in writing about the bed hold policy at the time of hospital transfer.
F 0657: The facility failed to update care plans for Residents #16 and #37 to reflect new diagnoses and significant medications including antidepressants and antianxiety drugs.
F 0658: The facility failed to meet professional standards by not following a physician's order for Resident #37 to complete a HgA1C lab test.
F 0760: The facility failed to prevent significant medication errors affecting Residents #5, #18, #32, and #37, including duplicate medication cards and missing doses of Eliquis.
F 0812: The facility failed to store and prepare food according to professional standards, with unlabeled food items and ice buildup in the freezer.
F 0883: The facility failed to offer influenza vaccine to Resident #36 and lacked documentation of offering, providing, or declining the vaccine.
F 0887: The facility administered a COVID-19 bivalent booster vaccine to Resident #23 without proper consent from the resident or representative.
Report Facts
Residents affected: 41
Medication cards: 14
Medication doses missed or duplicated: 3
Dates of medication orders: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Regional Director of Quality and Clinical Services | Confirmed medication errors, vaccine consent error, and care plan deficiencies |
| Staff B | Certified Medication Aide (CMA) | Reported medication variance for Resident #32 |
| Staff C | Certified Medication Aide (CMA) | Administered medications and reported on medication card usage |
| Staff H | Certified Medication Aide (CMA) | Reported on medication card handling and medication refusals |
| Staff A | Dietary Manager | Reported food storage and preparation deficiencies |
| Administrator | Verified deficiencies including bed hold notification, HgA1C testing, medication errors, and vaccine documentation | |
| DON | Director of Nursing | Reported on medication investigation and facility expectations |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 7
Date: Mar 27, 2023
Visit Reason
The inspection was an annual recertification survey combined with an investigation of complaint #110055 and #127835 conducted from March 20 to March 27, 2023.
Complaint Details
Complaint #110055 was substantiated. Facility reported incident #127835 was substantiated.
Findings
The facility was found not in compliance with several federal regulations including bed hold policy before transfer, care plan timing and revision, professional standards for services provided, medication administration errors, food safety requirements, immunization policies, and COVID-19 vaccination procedures. Multiple deficiencies were cited related to resident care, medication management, and facility policies.
Deficiencies (7)
Failure to provide written notice of bed hold policy at time of transfer for hospitalization or therapeutic leave.
Failure to update care plans timely to reflect new diagnoses and medications for residents.
Failure to meet professional standards of quality by not following physician's orders for medications.
Failure to prevent significant medication errors in 4 of 4 residents reviewed.
Failure to store and prepare food in accordance with professional standards; presence of expired or improperly stored food items.
Failure to ensure influenza and pneumococcal immunizations were offered and documented properly for residents.
Failure to ensure COVID-19 vaccinations were properly offered, consented, and documented for residents and staff.
Report Facts
Census: 41
Residents reviewed: 12
Residents with medication errors: 4
Deficiency completion dates: Apr 27, 2023
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective January 10, 2023.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Dec 20, 2022
Visit Reason
The investigation was conducted due to multiple intakes and self-reports related to quality of care concerns, specifically regarding falls and neurological assessments for residents #5 and #6.
Complaint Details
Complaint #105199-C was substantiated. Complaints #107926-C and #108177-I and self-reports #108936-I were not substantiated.
Findings
The facility failed to adequately assess residents after falls, with incomplete neurological assessments and documentation. The complaint #105199-C was substantiated, while other complaints and self-reports were not substantiated.
Deficiencies (1)
Failure to assure residents were adequately assessed after a fall for 2 of 3 residents reviewed (Residents #5 and #6), including lack of neurological status documentation per facility protocol.
Report Facts
Census: 48
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Johnston | Laboratory Director or Provider/Supplier Representative | Signed the Plan of Correction document |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 5
Date: Nov 22, 2021
Visit Reason
A recertification health survey and investigation of Complaint #100487 was completed on 11-22-21 to assess compliance with federal and state regulations.
Complaint Details
Complaint #100487 was investigated and found to be not substantiated.
Findings
The facility was found not to have completed required criminal/abuse background checks and dependent adult abuse training for newly hired staff. The facility also failed to provide bed-hold notices to residents or their representatives upon hospital transfer, did not consistently develop baseline care plans within 48 hours of admission, failed to keep medications secured, and did not maintain proper infection control practices including eye protection and COVID-19 testing protocols.
Deficiencies (5)
Facility failed to complete criminal/abuse background check and dependent adult abuse training for newly hired staff.
Facility failed to provide resident/resident representative notice of bed hold policy at time of hospital transfer for two residents.
Facility failed to develop and implement baseline care plan within 48 hours for residents.
Facility failed to keep medications secured in locked medication cart.
Facility failed to maintain infection control practices including eye protection for staff and proper COVID-19 testing and outbreak procedures.
Report Facts
Facility census: 56
Facility census: 63
Residents reviewed: 14
Residents reviewed: 3
Residents reviewed: 2
Residents reviewed: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in deficiency related to background check and dependent adult abuse training | |
| Staff A | Registered Nurse | Named in medication cart security deficiency |
| Director of Nursing | Director of Nursing | Provided statements regarding care plan and medication cart deficiencies |
| Administrator | Administrator | Provided statements regarding bed hold policy and infection control deficiencies |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Date: Jan 25, 2021
Visit Reason
A focused COVID-19 infection control survey and investigation of Complaints #86610-C, #87023-C, and #94044-C was conducted ending 1/25/21.
Complaint Details
Complaint #86610-C was substantiated. Complaint #87023-C was not substantiated. Complaint #94044-C was substantiated.
Findings
The facility was found not in compliance with CMS and CDC recommended practices to prepare for COVID-19. Deficiencies were identified related to incontinence care, catheter care, medication administration and destruction, infection prevention and control, and hand hygiene practices. Some complaints were substantiated while one was not.
Deficiencies (3)
Failure to provide complete incontinence care for residents requiring assistance, including proper catheter care and changing gloves when soiled.
Failure to ensure narcotics and controlled substances were destroyed with two staff witnesses and proper documentation.
Failure to ensure infection prevention and control practices, including changing gloves when soiled and sanitizing hands to prevent spread of infection.
Report Facts
Census: 56
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed providing incontinence care and assisting residents |
| Staff D | Certified Nursing Assistant (CNA) | Observed providing incontinence care and assisting residents |
| Staff C | Certified Nursing Assistant (CNA) | Observed providing catheter care and incontinence care |
| Staff E | Registered Nurse (RN) | Reported medication wastage and destruction |
| Staff F | Certified Medication Aide (CMA) | Reported medication wastage and destruction |
| Staff G | Reported staff documented amount of controlled medication wasted | |
| Staff H | Certified Medication Aide (CMA) | Reported medication wastage and destruction |
| Staff I | Licensed Practical Nurse (LPN) | Reported medication wastage |
| Staff J | Certified Medication Aide (CMA) | Reported medication wastage and destruction |
| Assistant Director of Nursing | Reported expectations for staff to change gloves and cleanse catheter tubing | |
| Director of Nursing | Reported staff wasted unused narcotics |
Inspection Report
Abbreviated Survey
Census: 75
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 75
Inspection Report
Routine
Census: 76
Deficiencies: 0
Date: Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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