Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Madison Medical Center during CMS and state inspections, most recent first.
QAPI meetings were not held with the required members present. The facility’s policy and QI Plan described monthly and quarterly QAPI/QI review with leadership, medical staff representation, and department supervisors, but meeting minutes showed the IP was absent from one meeting and the physician or NP was absent from two others. The Administrator stated she expected all required members to attend.
A facility failed to provide written transfer notices to the resident and/or representative for multiple residents who were sent to the hospital or ER and returned the same day. Record review showed no documentation of the required notice, including appeal rights and Ombudsman contact information, for seven sampled residents. Staff interviews described sending transfer paperwork, calling family and the physician, and treating ER trips as therapeutic leave.
Medication error rate exceeded during insulin pen administration. An LPN obtained FSBS readings for three residents, adjusted Humalog insulin pens to the ordered doses, and administered the insulin without priming the pens with two units as directed by the manufacturer. The facility had 25 opportunities with three errors for a 12% error rate, and the DON and Administrator stated they expected insulin pens to be primed before use and the medication error rate to remain at 5% or less.
Infection Control Failures During Wound Care: Two residents receiving wound treatment were cared for without proper infection control practices. An RN did not consistently use EBP, did not perform hand hygiene after touching contaminated items or between dirty and clean tasks, and reused gloves during multiple steps of wound care, including assessing another wound. For another resident, supplies were placed on the bed without a barrier, scissors and a marker were handled and stored without cleaning, and the RN used the same gloves throughout the dressing change and while initialing tape.
The facility failed to maintain proper infection control practices during incontinent care for two residents. CNAs involved in the care did not consistently perform hand hygiene between glove changes and tasks, violating the facility's handwashing policy. Observations showed CNAs handling soiled items and residents without washing or sanitizing hands. Interviews revealed inconsistencies in staff understanding and implementation of hand hygiene practices.
QAPI Meetings Lacked Required Members
Penalty
Summary
The facility failed to maintain quarterly QAPI meetings with the required members. Review of the facility’s QAPI policy dated July 2020 showed that the QAPI team was to meet monthly to discuss indicators and performance, and that representatives were also to meet quarterly with physicians, NPs, and other departments to report tracking results. However, the policy did not identify the required QAPI members, and the facility’s 2024-2025 QAPI Plan described a QI Team made up of leadership, medical staff representation, and department supervisors, with leadership reviewing quality performance monthly and a cross-functional team meeting on a periodic basis as established by the committee. Review of the QAPI meeting minutes showed that the IP did not attend the 11/15/24 meeting, the physician or NP did not attend the 02/14/25 meeting, and the physician or NP did not attend the 05/16/25 meeting. During interview, the Administrator stated there was an IP on the hospital side but it appeared there was not an IP at the November meeting, and that they would look at having another staff member obtain IP certification. She also stated that doctors or NPs usually attend the meetings, but she was not sure why they were not on the list or whether they were present, and said she would expect all required members to be at the meetings.
Missing Written Transfer Notices and Appeal Rights
Penalty
Summary
The facility failed to provide written notification to the resident and/or the resident's representative for hospital transfers, including the statement of appeal rights and the name, address, or telephone number of the Office of the State Long Term Care Ombudsman, for seven sampled residents. The deficiency was identified through interview and record review for Residents #5, #7, #8, #21, #24, #37, and #43 out of 15 sampled residents, with the facility census at 61. Record review showed that each of the affected residents had one or more transfers to the hospital or emergency room and returned to the facility the same day. For Resident #5, #7, #8, #21, #24, #37, and #43, the records did not contain documentation that written notification of the transfer was provided to the resident and/or the resident's representative. Resident #24 and Resident #43 each had multiple same-day hospital transfers documented, and Resident #5, #7, #8, #37, and #21 also had same-day transfers documented without evidence of written notice. The facility policy, Patient Transfer Form, revised July 2024, addressed sending the Continuity of Care Document with the resident, documenting a progress note, completing the nursing home transfer/bed hold observation, and Social Services reviewing and completing the bed hold notification. The policy did not address written notification of the transfer to the resident or responsible party. During interviews, nursing and administrative staff described sending transfer paperwork, calling family and the doctor, and mailing transfer/discharge information, while the Chief Operating Officer stated residents sent to the ER were considered on therapeutic leave and not classified as a transfer.
Medication Error Rate Exceeded During Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate of 5 percent or less during insulin administration. Based on observation, interview, and record review, there were 25 opportunities with three errors, resulting in a 12% error rate. The errors involved three residents outside of the 15 sampled residents, and the facility census was 61. Review of the facility's policy, Insulin Administration, revised 01/24, did not address the use of insulin pens. During observations on 09/25/25, an LPN obtained finger stick blood sugars for three residents and then retrieved Humalog insulin pens from the medication cart and adjusted each pen to the ordered dose, but did not prime the pens with two units of insulin before administering the doses. The manufacturer's directions for the insulin lispro pen stated to remove the cap, attach the needle, prime the pen by turning the dose selector to two units, press and hold the button until a drop of insulin appears, then select the dose and give the injection. In interview, the LPN stated he/she does not prime pens and explained the retractable needles prevented priming. The DON and Administrator later stated they would expect insulin pens to be primed before administration and for the medication error rate to be 5% or less.
Infection Control Failures During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care for two residents who were receiving treatment for wounds. The facility’s policies required wound care to be performed as a clean procedure with hand hygiene before and after glove use, glove changes when moving from dirty to clean tasks, and use of enhanced barrier precautions, including gown and gloves, for residents with wounds. The facility also had policies requiring handwashing or sanitizer use after contact with contaminated items and after removing gloves, and requiring scissors and markers used during care to be sanitized after use. During wound care for one resident with a wound on the left breast, the RN entered the room without donning a gown for enhanced barrier precautions, washed hands in the room, picked up the resident’s glasses from the floor, and then donned gloves without washing or sanitizing hands. The RN removed the old dressing and cleansed the wound without changing gloves, removed gloves and did not wash or sanitize hands, then donned gloves again to apply calcium alginate and tape. While wearing the same gloves, the RN assessed the resident’s right breast after the resident complained of pain. The RN then removed gloves, discarded trash, and washed hands. During wound care for another resident with a wound on the right foot, the RN and ADON donned gowns, washed hands, and donned gloves, but supplies were placed on the bed and scissors and tape were placed directly on the bed without a barrier. The RN used the same gloves to remove the dressing, clean the wound, apply xeroform and gauze, place tape, and initial the tape after reaching under the gown into a pocket for a marker. After the dressing was completed, the RN placed scissors and a marker on the counter, removed gown and gloves, washed hands, and then picked up the scissors and marker and placed them into a pocket without cleaning them.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinent care for two residents. During an observation of Resident #3, two CNAs were involved in providing perineal and catheter care. CNA A found bowel movement on their glove, removed the gloves, and placed them on a disposable bed pad without performing hand hygiene. CNA A then donned new gloves and continued cleaning the resident without washing hands. CNA C also failed to perform hand hygiene after removing gloves and before re-entering the room. Both CNAs continued to handle soiled items and the resident without proper hand hygiene, violating the facility's handwashing policy. In another instance, Resident #16 was observed receiving peri care from CNA A and CNA B. CNA A touched various surfaces in the resident's room before donning gloves and performing peri care. During the care, CNA A touched clean gloves with contaminated gloves and failed to perform hand hygiene after removing gloves. CNA B also did not perform hand hygiene after removing gloves and assisted in dressing the resident with bare hands. Both CNAs continued to handle the resident and their belongings without washing or sanitizing their hands, contrary to the facility's infection control policies. Interviews with the Infection Preventionist, CNA A, CNA B, and the Director of Nursing revealed inconsistencies in understanding and implementing hand hygiene practices. The Infection Preventionist emphasized the importance of hand hygiene with glove changes, while CNA B admitted to not always washing or sanitizing hands between tasks. CNA A acknowledged the need for sanitizing when moving from dirty to clean tasks. The Director of Nursing expected staff to perform hand hygiene with glove changes and before and after resident care, highlighting a gap between expected practices and actual staff behavior.
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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 Fredericktown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Claru Deville Nursing Center | 1 mi | ★★★★★ | 0 | 0 |
| St Francois Manor | 15.5 mi | ★★★★★ | 4 | 0 |
| Baptist Homes Of Arcadia Valley | 16.6 mi | — | 0 | 0 |
| Farmington Presbyterian Manor | 16.7 mi | ★★★★★ | 0 | 0 |
| Southbrook Nursing Center | 17.2 mi | ★★★★★ | 4 | 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.