Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Madrid Home For The Aged during CMS and state inspections, most recent first.
Care Plans Lacked Non-Pharmacological Interventions for Psychotropic Medications: The facility failed to identify non-pharmacological interventions and targeted behaviors for psychotropic use in 4 sampled residents. A resident with depression and cognitive deficits, a resident with Alzheimer's disease, depression, and bipolar disorder, a resident with depression and CVA, and a resident with dementia, anxiety, depression, and psychotic disorder were all receiving antidepressant, antipsychotic, and/or antianxiety medications, but their care plans did not include the required non-pharmacological interventions or targeted behaviors. The DON stated that such interventions should be listed for antipsychotic and antidepressant medications.
Unsafe food handling and unsanitary kitchenette refrigerators were observed during meal service and in resident snack areas. A Dietary Aide/Cook used the same contaminated gloves while plating multiple meals and handling ready-to-eat bread, then removed the gloves without sanitizing his hands. The second- and third-floor kitchenette refrigerators lacked proper temperature monitoring, had missing or incomplete temperature logs, and were dirty, with one refrigerator also containing an outdated cream cheese container. Staff gave conflicting statements about which department was responsible for the kitchenette areas.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
Cold Room Trays Delivered to Residents: Food and drink were not kept at an appetizing temperature for 3 of 5 residents reviewed. Residents with intact cognition reported that room trays were often cold, and observations showed the 3rd floor food cart was left in the hallway while trays and drinks were delayed. A sampled tray had hot foods measured at 109.8 degrees, 121.3 degrees, and 104.5 degrees, below the facility policy target of about 135 degrees.
Incomplete PBJ Staffing Submission: The facility failed to submit accurate PBJ staffing data because agency hours were omitted from the quarterly report. The Administrator stated the prior submission was incorrect, and the PBJ analysis later showed the missing hours had been corrected and no weekend staffing issue remained.
A facility failed to refer a resident for a Level II PASARR evaluation after a new diagnosis of schizoaffective disorder, bipolar type, was made. The resident, who was receiving antipsychotic and antidepressant medications, had a PASARR Level I Screen form that did not document any mental health diagnoses. The Director of Nursing confirmed the new diagnosis and the expectation for a status change to be submitted.
The facility failed to implement comprehensive care plans for four residents, leading to deficiencies in addressing specific needs and behaviors. A resident with cognitive impairment had multiple elopement attempts without care plan updates. Another resident at risk for elopement lacked a care plan addressing this risk. A resident with schizoaffective disorder did not have a care plan for managing behaviors, and a resident with a traumatic brain injury was observed without a recommended wrist brace, indicating a lack of communication and implementation of care plan interventions.
The facility failed to obtain physician orders for indwelling catheters for two residents, one with traumatic spinal cord dysfunction and another with spastic quadriplegic cerebral palsy. Both residents had catheters in place without documented orders, violating professional standards of care.
Care Plans Lacked Non-Pharmacological Interventions for Psychotropic Medications
Penalty
Summary
The facility failed to identify non-pharmacological interventions and targeted behaviors related to psychotropic medications for 4 of 5 sampled residents reviewed. Resident #2 had a BIMS score of 14 and diagnoses of depression, metabolic encephalopathy, and cognitive communication deficit, and was receiving duloxetine 120 mg daily; the care plan revised on 3/6/26 did not include non-pharmacological interventions or targeted behaviors for the antidepressant. Resident #29 had a BIMS score of 15 and diagnoses of Alzheimer's disease, depression, and bipolar disorder, and was receiving quetiapine 50 mg daily, quetiapine 25 mg daily, and trazodone 25 mg daily; the care plan revised on 12/29/25 lacked non-pharmacological interventions and targeted behaviors for the antidepressant and antipsychotic medications. Resident #1 had a BIMS score of 14 and diagnoses of depression, CVA, and dysphagia, and was receiving bupropion 300 mg daily and duloxetine 90 mg daily; the care plan revised on 2/16/26 lacked non-pharmacological interventions and targeted behaviors for the antidepressant and antianxiety medication. Resident #4 had a BIMS score of 11 and diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder, and was receiving risperidone 0.5 mg daily, sertraline 75 mg daily, and lorazepam 0.5 mg every 12 hours as needed for anxiety for 14 days; the care plan revised on 2/16/26 lacked non-pharmacological interventions and targeted behaviors for the antidepressant, antianxiety, and antipsychotic medications. The DON stated that non-pharmacological interventions should be listed on the care plan for antipsychotic medications as well as antidepressants.
Unsafe Food Handling and Unsanitary Kitchenette Refrigerators
Penalty
Summary
The facility failed to prepare, serve, and distribute food in accordance with food service safety during the noon meal service in the kitchen. A Dietary Aide/Cook wore the same pair of disposable gloves while handling multiple surfaces and tasks, including touching a plate, tongs, a scoop, a ladle, an insulated meal cart, and the cart door before handling ready-to-eat sliced bread with those same gloves. He used the same gloves while plating three meals and did not sanitize his hands after removing the gloves. During interview, he agreed he had touched multiple surfaces before handling the ready-to-eat bread, and the Dietary Manager stated she expected dietary staff to use tongs with the ready-to-eat sliced bread. The facility also failed to ensure sanitary and safe conditions in the second- and third-floor kitchenette refrigerators used for resident snacks, nourishments, condiments, and other food items. In the second-floor kitchenette, there was no thermometer in the refrigerator, the posted temperature check form had blank location, month, and year fields, and the refrigerator interior was dirty with debris on the shelves and dried juice on the bottom. Seven temperature entries were recorded as 38 F and 39 F. In the third-floor kitchenette, there was no temperature check form posted, the refrigerator had a dried brown substance on the bottom shelf, and a partially used garlic herb cream cheese container dated 10/28/25 was found in a bottom drawer. During interviews, staff gave conflicting statements about which department was responsible for the kitchenette refrigerators. The Scheduling Coordinator stated dietary was responsible for the refrigerators and that a temperature check form should have been posted. The DON stated dietary was responsible for monitoring the second- and third-floor kitchenettes, while the Dietary Manager later stated nursing was responsible for monitoring the kitchenettes and the cleanliness and proper temperature of those refrigerators. The Administrator stated he had started the role the prior week and did not know who was responsible for the kitchenette areas.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Cold Room Trays Delivered to Residents
Penalty
Summary
Food and drink were not provided at a safe and appetizing temperature for 3 of 5 residents reviewed, including residents with intact cognition based on BIMS scores of 14 and 15. Resident interviews indicated that food served on room trays was often cold when delivered, with one resident stating this happened frequently and another stating the food was often served cold when delivered on room trays. Observations showed the 3rd floor food cart was delivered to the unit and left in the hallway by the nurses' office, and room trays were not delivered promptly. During one observation, the cart doors were left open while trays were being delivered, and during another, drinks were not prepared until 17 minutes after the cart arrived, while the food sat in the cart. A sampled tray showed hot foods at 109.8 degrees, 121.3 degrees, and 104.5 degrees. The CDM stated she would have liked to see the food temperatures higher when delivered to the floor for room trays, and the Administrator stated he would expect food temperatures to be at the appropriate temperatures. The facility policy stated hot foods should stay about 135 degrees and should be transported quickly to maintain temperatures for delivery and service.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate PBJ staffing information based on payroll and other verifiable and auditable data for Quarter 1, 2026. The PBJ Staffing Data Report for October 1 through December 31 triggered for excessively low weekend staffing, and the facility reported a census of 54 residents. Review of the facility policy showed that agency and contract staff hours were required to be included in the quarterly PBJ submission. During interview, the Administrator stated the PBJ information had been submitted incorrectly by the previous Administrator because agency staff hours for October 1 through December 31 were not submitted. The Administrator also stated that on March 9 the Clinical Specialist audited agency invoices and found the PBJ hours were incorrect, and that the missing agency hours had been resubmitted to correct the report. Review of the current PBJ Analysis Summary for the quarter showed the hours had been corrected and no issue remained for excessively low weekend staffing.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination. This deficiency was identified for a resident who was newly diagnosed with a mental disorder. The resident, who had a Minimum Data Set assessment dated April 6, 2024, was diagnosed with schizophrenia and depression and was receiving antipsychotic and antidepressant medications daily. However, the resident's PASARR Level I Screen form from February 24, 2021, did not document any mental health diagnoses. A new diagnosis of schizoaffective disorder, bipolar type, was recorded on March 1, 2023, during the resident's stay at the facility. During an interview on June 4, 2024, the Director of Nursing confirmed the new diagnosis and acknowledged the expectation for a status change to be submitted with the new diagnosis and medication started.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their specific needs and behaviors. Resident #31, with moderate cognitive impairment and a history of elopement attempts, did not have a care plan that addressed elopement concerns and behaviors. Despite multiple incidents in April 2024 where the resident attempted to leave the facility, the care plan was not updated to include interventions or goals related to these behaviors. Resident #4, also with moderate cognitive impairment and at risk for elopement, lacked a care plan addressing elopement concerns. An elopement evaluation identified the resident as at risk, yet the care plan did not include any focus area, goals, or interventions to mitigate this risk. The Director of Nursing acknowledged the oversight and the expectation for the care plan to address such concerns. Resident #17, with intact cognition and a diagnosis of schizoaffective disorder, did not have a care plan that included focus areas or interventions for managing related behaviors. Despite receiving the diagnosis and starting antipsychotic medication in March 2023, the care plan was not updated to reflect these needs. Additionally, Resident #39, with a history of traumatic brain injury and functional impairments, was observed without a wrist brace as recommended by therapy. Staff were unaware of the need for the brace, indicating a lack of communication and implementation of care plan interventions.
Failure to Obtain Physician Orders for Indwelling Catheters
Penalty
Summary
The facility failed to adhere to professional standards by not obtaining physician orders for indwelling catheters for two residents. Resident #26, who has a history of traumatic spinal cord dysfunction, neurogenic bladder, quadriplegia, and seizure disorder, was readmitted to the facility with an indwelling catheter. However, the Treatment Administration Records (TAR) from February to June 2024 lacked any physician orders for the catheter, including details on when it should be changed. The facility's catheter insertion procedure guide requires checking for a physician order for the type and size of catheter and related diagnosis, which was not followed. The Director of Nursing (DON) acknowledged that the orders were discontinued when the resident went to the hospital in April 2023 and should have been transcribed correctly upon readmission. Similarly, Resident #10, diagnosed with spastic quadriplegic cerebral palsy, was observed with an indwelling urinary catheter in place. However, the electronic record of the Physician Order Summary Report lacked an order for the catheter. This oversight indicates a failure to maintain proper documentation and obtain necessary physician orders for medical devices, which is a breach of professional standards of care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Madrid
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Granger Nursing & Rehabilitation Center | 8 mi | ★★★★★ | 4 | 0 |
| On With Life Long Term Care | 9.1 mi | ★★★★★ | 2 | 0 |
| Green Hills Health Care Center | 12.7 mi | ★★★★★ | 1 | 0 |
| Perry Lutheran Homes Eden Acres Campus | 13 mi | ★★★★★ | 3 | 0 |
| Westhaven Community | 13.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.