Inspection Reports for
The Madison Health and Rehabilitation Center
111 Kelly Blvd, Madison, MS, 39110
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Inspection Report — Jan 16, 2025
Routine CMS
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, accurate assessments, care planning, activities of daily living, medication storage, food safety, and infection control at The Madison Health and Rehab nursing facility.
Findings
The facility was found deficient in honoring residents' rights to make healthcare decisions, accurately coding assessments, implementing comprehensive care plans, providing adequate ADL care including oral hygiene and nail care, properly storing medications, ensuring adaptive feeding equipment was provided, maintaining proper food labeling and storage, and following enhanced barrier precautions for infection control.
Deficiencies (8)
Failed to honor resident's rights to make health care decisions for three residents by not obtaining their signatures on code status forms.
Failed to accurately code section A of the Minimum Data Set for a resident with serious mental illness.
Failed to implement a comprehensive care plan for personal hygiene and adaptive equipment for meals for three residents.
Failed to provide nail care, oral care, and facial hair removal for residents requiring assistance with activities of daily living.
Failed to properly store medications; medications were left in a resident's room without assessment for self-administration.
Failed to provide a resident with adaptive equipment during meals as ordered.
Failed to ensure food items in the walk-in kitchen refrigerator were properly labeled, dated, discarded by expiration date, and arranged to prevent cross-contamination.
Failed to follow Enhanced Barrier Precautions while providing care to residents with indwelling medical devices.
Report Facts
Residents reviewed for advanced directives: 24
MDS reviewed: 16
Care plans reviewed: 16
Residents sampled for ADL care: 16
Residents sampled for medication storage: 16
Dining observations: 2
Kitchen tours: 3
Direct care observations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed residents' cognitive ability and care plan expectations; confirmed medication and infection control deficiencies. | |
| Social Services Director | Confirmed code status discussions were held with family representatives, not residents. | |
| MDS Nurse | Confirmed inaccurate coding and care plan non-compliance. | |
| Certified Nursing Assistant (CNA) #1 | Confirmed long fingernails and facial hair issues. | |
| Licensed Practical Nurse (LPN) #1 | Confirmed medication storage and infection control issues. | |
| Licensed Practical Nurse (LPN) #2 | Observed not wearing gown during PEG tube medication administration. | |
| Registered Nurse (RN) Supervisor | Confirmed oversight responsibilities for ADL care. | |
| Dietary Manager (DM) | Confirmed food labeling and storage deficiencies. | |
| Dietary Aide | Confirmed food labeling and dating procedures not followed. |
Inspection Report — Sep 21, 2023
Annual Inspection CMS
Date: Sep 21, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with safety regulations, specifically focusing on the safe storage and locking of hazardous cleaning chemicals in the nursing home.
Findings
The facility failed to safely store and lock hazardous cleaning chemicals on four of five housekeeping carts observed. Multiple observations and interviews confirmed that chemicals were left unattended and unlocked, posing potential harm to residents. The housekeeping supervisor and staff lacked proper training and keys to secure the carts, despite receiving in-service training earlier in the year.
Deficiencies (1)
Failure to safely store and lock hazardous cleaning chemicals on housekeeping carts, leaving chemicals unattended and accessible to residents.
Report Facts
Housekeeping carts with unsafe chemical storage: 4
Housekeeping carts used daily: 5
In-service training dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Confirmed chemicals should be locked when unattended and acknowledged potential harm to residents. | |
| Housekeeper #2 | Confirmed chemicals should not be left unattended and cabinets locked; stated she did not have a key to lock her cart. | |
| Housekeeping Supervisor | Housekeeping Supervisor | Confirmed presence of chemicals on carts, lack of keys, lack of training at start of position, and attendance at in-service trainings. |
| Administrator | Administrator (ADM) | Confirmed chemicals were left unattended and keys to lock carts were missing; confirmed training of Housekeeping Supervisor. |
| Director of Nursing | Director of Nursing (DON) | Confirmed no wandering residents and no incidents involving chemicals in the past 12 months. |
Inspection Report — May 11, 2023
Plan of Correction CMS
Date: May 11, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a survey completed on 05/11/2023 for The Madison Health and Rehab facility.
Findings
No health deficiencies were found during the survey.
Inspection Report — Apr 7, 2022
Routine CMS
Date: Apr 7, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, incomplete PASARR screenings, inadequate comprehensive care plans, improper monitoring of wandering residents, improper labeling of feeding tubes, food safety violations, infection control lapses during medication administration, and failure to ensure staff COVID-19 vaccination compliance. Additionally, the call light system volume was insufficient to alert staff timely.
Deficiencies (12)
Failure to ensure resident dignity and privacy including verbal communication during care, knocking before entering rooms, covering residents during care, and providing privacy bags for catheter drainage.
Failure to complete PASARR Level I Assessment upon admission for Resident #34.
Failure to complete Change in Status Form for Resident #34 to trigger PASRR Level II Assessment after mental status change.
Failure to develop and implement comprehensive care plans for Residents #19, #20, and #42 addressing medical, nursing, mental, and psychological needs.
Failure to utilize assistive communication devices for Resident #20, who is deaf and mute, resulting in ineffective communication.
Failure to provide personal hygiene care evidenced by long, jagged fingernails and white material in hair for Residents #19 and #42.
Failure to adequately monitor and supervise Resident #46 who wanders into other residents' rooms, posing safety risks.
Failure to label and date feeding tube formula bottles for Resident #5, risking contamination and resident safety.
Failure to prevent possible food contamination due to improper thawing of raw chicken and storage of expired sandwich bread.
Failure to provide proper barrier during medication administration and failure to ensure catheter bag was properly positioned and covered for privacy for Residents #1, #33, and #42.
Failure to ensure all staff were fully vaccinated against COVID-19 or had granted exemptions, with two CNAs working without full vaccination.
Failure to provide sufficient volume level on the resident call light system, resulting in inability to hear call lights on nursing unit halls.
Report Facts
Residents reviewed for care plans: 24
Residents receiving dietary trays: 53
Residents affected by call light system issue: Many
Employee records reviewed: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #6 | Certified Nurse Assistant | Observed and interviewed regarding resident dignity and wandering resident #46 |
| CNA #7 | Certified Nurse Assistant | Observed and interviewed regarding resident dignity and communication |
| CNA #8 | Certified Nurse Assistant | Interviewed regarding resident dignity and wandering resident #46 |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident dignity, feeding tube labeling, and wandering resident #46 |
| RN #1 | Registered Nurse | Observed medication administration and interviewed regarding infection control |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, care plans, infection control, wandering, and COVID-19 vaccination |
| Administrator | Facility Administrator | Interviewed regarding COVID-19 vaccination compliance, call light system, and wandering resident #46 |
| Social Worker | Social Worker | Interviewed regarding PASARR assessments and communication device for Resident #20 |
| Dietary Department Manager | Dietary Department Manager | Interviewed regarding food thawing and expired food |
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